We are looking for a Medical Records & Clinical Documentation Executive to ensure timely and accurate preparation of discharge summaries and completion of clinical documentation.
Key Responsibilities
Coordinate and Prepare discharge summary drafts based on the clinical information and documentation provided by the treating doctor and concerned departments.
Review the availability and completeness of required documentation before initiating discharge summary preparation.
Plan and initiate discharge summary preparation in advance based on the expected discharge schedule.
Coordinate with treating doctors for preparation, review, correction, completion, and authorization of discharge summaries.
Ensure patient identification details and other demographic information are accurate and correctly documented.
Ensure discharge summaries are prepared, completed, verified, and made available within the stipulated time frame.
Monitor documentation deficiencies and report recurring issues to the concerned department.
Maintain confidentiality and security of patient medical records and information.
Perform other duties related to medical records and clinical documentation as assigned by the management.
Eligibility
- Graduate / relevant healthcare qualification preferred.
- 1–2 years of experience/Freshers with valuable knowledge - medical terminology and hospital documentation.
- Basic computer skills and experience in HIS/EMR preferred.
- Good communication and coordination skills.
- Ability to coordinate and follow up with doctors and multiple hospital departments.
- Ability to work within stipulated timelines and handle time-sensitive documentation.