24 Aug
|
Sahrudaya Health Care
|
Bengaluru
24 Aug
Sahrudaya Health Care
Bengaluru
Role & responsibilities
ChatGPT said
Roles & Responsibilities of a Medical Record Technician in a Hospital A Medical Record Technician (MRT) is responsible for maintaining, organizing, securing, and retrieving patients medical records while ensuring that documentation is accurate, complete, and confidential.
1. Medical Record Management
- Create and maintain patient medical records.
- Collect and organize medical documents from different hospital departments.
- File and retrieve records efficiently.
- Ensure records are complete, accurate, and properly arranged.
- Maintain both physical and electronic medical records.
2. Patient Registration & Identification
- Verify patient demographic and identification details.
- Create medical record numbers and maintain accurate patient identification.
- Avoid duplicate medical records.
- Update patient information when required.
3. Documentation & Data Entry
- Enter patient information accurately into the hospital information system.
- Check medical records for missing or incomplete documentation.
- Ensure reports, discharge summaries, investigation results, and treatment records are properly filed.
- Assist in maintaining standardized medical documentation.
4. Discharge Record Management
- Collect and organize records after patient discharge.
- Check discharge files for completeness.
- Coordinate with doctors and departments for missing documents.
- Prepare records for medical record review and coding, where applicable.
5. Medical Coding & Classification
- Assist with assigning appropriate diagnosis and procedure codes according to applicable coding standards and hospital policies.
- Review documentation to support accurate coding.
- Identify discrepancies and coordinate clarification with the concerned department.
6. Record Retrieval
- Retrieve medical records for doctors, nurses, departments, audits, insurance claims, and authorized requests.
- Track records issued to different departments.
- Ensure timely return and proper filing of records.
7. Confidentiality & Privacy
- Maintain strict confidentiality of patient information.
- Release medical records only to authorized persons according to hospital policy and applicable law.
- Protect records from unauthorized access, loss, damage, or alteration.
8. Statistics & Reporting
- Collect and compile hospital statistics such as:
- Admissions
- Discharges
- Deaths
- Length of stay
- Outpatient visits
- Bed occupancy
- Prepare routine medical-record reports for hospital management.
- Support data collection for audits and accreditation.
9. Quality & Audit
- Conduct medical record completeness checks.
- Identify missing signatures, reports, diagnoses, or other required documentation.
- Participate in medical record audits.
- Support quality improvement and hospital accreditation activities.
10. Coordination With Hospital Departments
- Coordinate with doctors, nursing staff, laboratory, radiology, billing, insurance, and other departments.
- Follow up on incomplete or missing documentation.
- Support smooth flow of patient information within the hospital.
11. Electronic Medical Records (EMR)
- Maintain electronic patient records accurately.
- Perform data entry and record updates in the hospital information system.
- Assist users with basic medical-record-related system issues.
- Follow appropriate access-control and data-security procedures.
12. Legal & Retention Responsibilities
- Maintain records according to hospital retention policies and applicable regulations.
- Ensure proper documentation for medico-legal cases.
- Preserve records required for legal, insurance, audit, or regulatory purposes.
- Assist with authorized release of records and medical information.
Preferred candidate profile
- Must have experience as MRD incharge.
- Preferring candidate with immediate joiner
📌 Medical Record Incharge (Bengaluru)
🏢 Sahrudaya Health Care
📍 Bengaluru