- Custodian of Medical Records: Ensure accurate, secure, and confidential handling of patient medical records as per hospital policies and legal standards.
- Compliance & Standardization: Maintain medical records in compliance with NABH, JCI, and other accreditation standards.
- Data Management & Retrieval: Oversee proper filing, indexing, and timely retrieval of patient records for internal use or legal purposes.
- Information Accuracy & Quality Control: Ensure completeness and correctness of patient files including admission details, discharge summaries, investigation reports, and consent forms.
- Coordination & Communication: Act as a bridge between clinical departments, billing, and administration for record-related queries.
- Confidentiality & Security: Safeguard patient information against unauthorized access, loss, or damage.
Key Responsibilities:
✅ Record Maintenance
- Organize and maintain medical records for admitted and discharged patients.
- Ensure that all patient files have proper documentation, signatures, and mandatory forms.
✅ Filing & Indexing
- Implement systematic filing methods (manual or digital) for easy accessibility.
- Update MRD register and electronic health record systems regularly.
✅ Compliance
- Ensure medical records are maintained as per NABH guidelines.
- Assist during NABH audits by providing required documentation.
✅ Coding & Data Entry
- Assign ICD codes for diseases and procedures where applicable.
- Enter patient data accurately in hospital software.
✅ Confidentiality & Legal Compliance
- Adhere to legal requirements regarding record retention and confidentiality.
- Provide medical records for medico-legal cases as per hospital policy.
✅ Reporting
- Prepare statistical reports like daily admissions, discharges, and mortality rates.
- Submit periodic MIS reports to management.
✅ Support for Clinical & Administrative Teams
- Provide necessary records for clinical audits, research, and quality improvement programs.
- Support billing and insurance teams by verifying documents.
✅ Record Disposal
- Oversee protected disposal of old records after the retention period with proper authorization.
Job Type: Full-time
Benefits:
- Paid sick time
- Provident Fund
Ability to commute/relocate:
- Mohali, Punjab: Reliably commute or planning to relocate before starting work (Required)