Job Purpose

To lead and manage the Medical Records Department (MRD), ensuring accurate, complete, secure, and timely management of patient health records across the hospital. The role is responsible for medical records governance, documentation compliance, legal and statutory requirements, digitization initiatives, record retrieval, data quality, and adherence to NABH/JCI standards while supporting clinical, operational, insurance, and medico-legal functions.
Key Accountabilities

A. Medical Records Operations Management
Oversee end-to-end management of inpatient, outpatient, emergency, daycare, and procedural medical records.
Ensure accurate collection, verification, indexing, storage, retrieval, tracking, and archiving of records.
Monitor record movement across departments and maintain complete traceability.
Establish and monitor MRD operational standards and service levels.

Key Deliverables
Timely record availability
Record retrieval efficiency
Zero record loss incidents
Department productivity metrics

B. Clinical Documentation Compliance




Ensure completeness and accuracy of clinical documentation including:
Admission records
Progress notes
Consent forms
Operative notes
Anaesthesia records
Discharge summaries
Death summaries
Conduct regular documentation audits.
Coordinate deficiency management with consultants, RMOs, nursing, and clinical departments.
Ensure timely closure of documentation deficiencies.

Key Deliverables
Documentation completeness score
Discharge summary compliance
Documentation deficiency closure rate
Clinical audit scores

C. Medical Records Governance & Confidentiality
Establish robust policies for record management and health information governance.
Ensure confidentiality and privacy of patient information.
Manage authorized access and release of medical information.
Ensure adherence to hospital policies and legal requirements concerning medical records.

Key Deliverables
Infor

📌 Manager Mrd Mumbai
🏢 Sir Hn Reliance Foundation Hospital
📍 Mumbai