Job Description

Job Summary

Responsible for carrying-out all procedures as they relate to the organization of all patient medical records

.Responsible for Assembly and Analysis (OP/IP), loose reports collecting and filing, creating new folders after the discharge of the patient. To ensure that each in-patient medical records contains necessary documentation, reports, tests results, or other required elements as per departmental policy based on CBAHI and JCIA standards

.Retrieve record as requested

.Responsible for notifying all physicians of their incomplete medical records monthly to comply with hospital policy. All queries from Physicians are referred to this policy

.Proper file maintenance has to be maintains in the master record filing area

.Auditing of files will be carried-out

.Is able to work independently with minimal direct supervision

.
Major Duties and Responsibiliti

es
Outpatient Record Retrieval / Fil

• ing
  Retrieves all medical records upon request (walk-in patients and ER patie
• nts)Retrieves booked outpatient appointment for next day and filing back the returned patients rec
• ord.Reviews and assembles Medical records after retri
• evalPrepares medical record folders for new patie
• nts.Inserts all incoming reports throughout each shift to prevent back
• log.Maintains all shelving areas in accurate terminal digit order by periodically performing file aud
• its.Complies with the departmental policies and procedures in addition to the general hospital’s policies governing all staff memb
• ers.Routing the records to the outpatient and inpatient departments when it’s urgently needed for the patient c
• are.Maintains accurate, neat files in a timely man
• ner.Maintains confidentiality, security and personal privacy of all patient information and fi
• les.Places records on appropriate shelving area, i.e. permanent filing area, incomplete, coding and
• etc.Perform other duties as requi

red.Assembly and Anal

• ysis
  Responsible for collection of discharged medical records not forwarded to HIM Department within 24 hours of disch
• arge.Assemble the unorganized document according to the standard assembling order (CBAHI and JCIA standard) of the discharged patient’s rec
• ords.Analyze the medical record file for missing documents as per policy and indicate by f
• lags.Assign deficient record to every physician responsible for dictating Rep
• orts.Maintains accurate, neat files in a timely ma
• nner.Maintains confidentiality, security and personal privacy of all patient information and f
• iles.Enter and maintains the computerized Medical Record Deficiency sy
• stem.Work is conducted in a professional manner maintains patient / staff confidentiality when requ
• ired.Performs other applicable tasks and duties assigned within the realm of the employee’s knowledge, skills and du
• ties.Contact the Concerned physician and inform them about their deficient f

iles.

Physician Com

• pletion
  Retrieves the delinquent records list from the computer with physician ID# a
• nd name.Retrieves all incomplete medical records as re
• quested.Notifies physicians of their incomplete medical records by sending reminder letter weekly (first day) to comply with the hospital
• policy.Forward the lost notification at the end of the third week about the delinquent record holder physician name to the adminis
• tration.Maintains the computerized medical record deficiency system by updating and clearing the medical records and respective physician deficiency profile as physicians complete their
• records.Maintains confidentiality, security and personal privacy of all patient information an
• d files.Maintains accurate, neat files in a timely
• manner.Re-analyzes all medical records determined to be completed before forwarding to the clinical coding section for discharge a
• nalysis.Obtains counter-signature from consultants before first week of ever
• y month.Submits a weekly and monthly report on the number of delinquent records by physician department and type of deficiencies, i.e. signature, H & P’s, operation notes and discharge summaries as per p
• olicies.Performs applicable tasks and duties assigned within the realm of the employee’s knowledge, skills and

duties

• .
  GeneralParticipates in on-going education program developed by the department, e.g. department policies and procedures, Fire and Safety, Risk Management, Environmental
• control.Participates in Monthly meeting to ensure that all the staff completing their job description according to the policy and procedure of the department and discussing current issues to keep the quality to the patient care
• services.Complies with hospital dr

ess code.
Re

• porting to
  HIM Coordinator/Di

rector/Head
Qua

• lifications:
  Diploma in Medical Record Science

/ Technolo

• gy
  Experience:At least (1) year experience working in Medical record department performing Te

chnical tasks.
Special requi

• rements/skills:Fluency in verbal and w
• ritten English.Must possess complete familiarity with required medical record documentation, medical terminology, Anatomy, Physiology
• and Pathology.Must possess thorough comprehension of the HIS system as it relates to the HIM department and utilize that knowledge for practica
• l applications.Ability to operate computerized health information system as required by departme
• ntal functions.Ability to understand diverse docume
• ntation styles.Exhibits professionalism and excellent interpersonal commun

ication skills.