Key Responsibilities

A.

Medical Records

Management

- Maintain and organise all Inpatient (IP), Outpatient (OP) and Emergency (ER) medical records.

- Ensure proper filing, indexing, numbering and storage of patient case sheets.

- Maintain patient medical records in physical and electronic formats.

- Ensure that records are properly labelled with patient identification details.

- Retrieve and issue medical records to authorised departments when required.

- Track the movement of case files and ensure timely return to the MRD.

B.

Discharge

Summary and Documentation

- Verify the completeness of inpatient case sheets before filing.

- Check discharge summaries, admission forms, consent forms and treatment records for completeness.

- Ensure that doctors' signatures, dates, times and other required entries are present.

- Follow up with the concerned departments for missing documents or incomplete records.

- Ensure that discharge documentation is properly compiled and filed.

- Report incomplete or unsigned records to the concerned department or authorised supervisor.

C.

Medical Records

Audit

- Conduct regular audits of inpatient and outpatient medical records.

- Check for missing documents, incomplete forms, missing signatures and documentation discrepancies.

- Maintain a checklist for medical record completion.

- Prepare monthly reports on documentation compliance and record deficiencies.

- Coordinate with nursing, doctors, billing and other departments to rectify deficiencies.

D. Confidentiality and Record Security





- Maintain strict confidentiality of patient information.

- Prevent unauthorised access, disclosure, loss or damage of medical records.

- Release copies of medical records only to authorised persons following hospital policy and applicable law.

- Maintain a register for medical record requests and record releases.

- Ensure secure storage and appropriate access controls for electronic records.

- Report any suspected loss, breach or unauthorised disclosure of patient information immediately.

E.

Record

Retention and Disposal

- Maintain a medical records retention register.

- Ensure records are preserved for the applicable statutory and hospital-defined retention periods.

- Maintain records in a secure, clean and systematic storage area.

- Ensure that records are disposed of only after the applicable retention period, with proper authorisation and documentation.

- Support digitisation, scanning and archiving activities wherever implemented.

F. Coordination with Hospital Departments

- Coordinate with Front Office, EMR, Nursing, Doctors, Billing, Insurance and Administration teams.

- Ensure timely receipt of completed patient files from the wards and nursing stations.

- Provide records required for authorised insurance claims, audits and medico-legal purposes.

- Support NABH documentation, internal audits and quality improvement activities.

- Assist in retrieving records for authorised patient care reviews and administrative requirements.

Work Location: In person

📌 Medical Records Department (MRD) (Bengaluru)
🏢 Evani Multispeciality Hospital
📍 Bengaluru