- Ensure completeness and compliance of patient documentation, including assessments, care plans, nursing notes, visit records and discharge/closure records.
- Monitor consent form compliance, ensuring required consents are complete, appropriately signed and maintained.
- Conduct periodic medical record audits to identify documentation gaps and drive timely closure.
- Ensure document control for Homecare forms, formats, SOPs and checklists, including version control and withdrawal of obsolete documents.
- Monitor continuity-of-care documentation, including handovers, changes in patient condition, interventions, escalation and referrals.
- Maintain compliance trackers and dashboards and report key gaps, trends and recurring non-compliances to Nursing/Operations leadership.
- Support internal audits, quality reviews and NABH/accreditation readiness, including evidence preparation and CAPA follow-up.
- Coordinate with Nursing, Clinical, Operations and Quality teams to strengthen documentation practices and drive continuous improvement.
Preferred candidate profile
- Strong documentation and record-management skills
- Good understanding of healthcare/nursing documentation and consent processes
- Audit and compliance orientation with solid attention to detail
- Good MS Office / Excel and reporting skills
- Ability to identify gaps, trends and recurring non-compliances
- Strong follow-up and coordination skills
- Understanding of patient confidentiality and medical-record security
- Good communication and stakeholder-management skills
Qualification: Bachelor's degree in any discipline, Nursing Qualification will be preferred but not mandatory