Role & Responsibilities
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
Solid documentation and record-management skills
Positive understanding of healthcare/nursing documentation and consent processes
Audit and compliance orientation with strong 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
Valuable communication and stakeholder-management skills

Qualification: Bachelor's degree in any discipline, Nursing Qualification will be preferred but not mandatory

📌 Executive/sr Executive Homecare Clinical Records / Documentation Gurugram
🏢 Medanta
📍 Gurugram