Assembling the Inpatient case records in the form of order of arrangement of the case sheets
Collecting death information from the wards and preparing death reports to be sent to Corporation with acknowledgement.
Receiving all discharges/ death records from all the wards
To carry out other duties and functions related to Medical Record Services as instructed by the immediate chief.
To carry out technical analysis and evaluation of medical records in accordance with hospital standards.
To cooperate with all departments related to medical record services in order to obtain acceptable records for providing efficient services.
To cooperate with the medical, nursing and other staff in completing patient medical records.
To establish, organize and manage medical record department with appropriate systems to provide an effective service in the hospital.
To evaluate documentation for deficiencies in the inpatient medical files and to arranging for completion of records with the cooperation of medical and nursing staff.
To observe and maintain medical ethics as recommended for medical record heads
To observe professional ethics and to protect the confidentiality of information from authorized person; to keep medico-legal records under safe custody and to attend court whenever required.
To participate in educational programs such as seminars, workshops, and conferences related to medical record fields.
To perform any other work related to medical records as instructed by his or her direct or immediate chief.
To prepare and maintain medical reports, and medical certificates, death registers and to notify concerned authorities in duly completing the required procedures.
To prepare monthly statistical reports concerning the hospital activities carried out, and to submit to concerned authorities any suggestions for improvements.
To protect medical records especially MLC from unauthorized disclosure so as to maintain confidentiality.
To review the medical records of outpatients, inpatients and emergency patients to ensure that they include all important documents and patient information.
To scan the complete patient record to the computer for processing, storage, and retrieval when required.
To supply patient files in accordance with the established procedures for medical care, medical education, medical training, medical care evaluation management, and legal purposes.
To do a close audit of paper and evaluate percentages of
Percentage of Medical Records not having discharge summary
Percentage of medical records not having initial assessment / Care Plan
Percentage of medical records with incomplete consent form
Percentage of Total Medical Records not completed
Percentage of missing records
Percentage of Inpatient Medical Records Not having ICD Code
