- 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
- Bed Occupancy rate
- Average Length of Stay
- Total Number of Outpatients
- Total Number of Inpatient
- Total Number of Discharges
- Number of MLC Cases reported
- Notifiable Disease
- Total deaths/months
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