- To assemble and punch the inpatient records as per the established assembling procedures.
- To code and index diseases, surgical operations and therapeutic procedures according to International Classification of Diseases (ICD-10).
- To feed patient care information into the computer for processing, storage and retrieval when required. (Disease & Procedure Code Mapping)
- To review the medical records of outpatients, inpatients, emergency patients and diseased patients to ensure that they include all important documents and pertinent information.
- To cooperate with the medical, nursing and other staff persons in completing patient medical records.
- To prepare deficiency statistics like ward wise, doctor’s wise.
- To strictly observe instructions given in the procedure manual to carry out assigned duties and responsibilities.
- To maintain the confidentiality of patient information and prevent disclosure to unauthorized persons.
- To prepare monthly, yearly patients statistics.
- To prepare the daily census and send to top management.
- To prepare quality monitor statistics and respective graph.
- To collect medical, administrative and other statistics required by the hospital and to provide health information for planning and evaluation of health care through the head of the department.
- To maintain accident report and police intimation books.
- To check the scanned files and copy into the computer.
- To prepare wound certificate and issue when requested.
- Process all insurance claim forms received at MRD.
- To prepare the statistics and records for clinical and audit meetings.
- To attend to patient/representative calls on amendment of identification data, name query, photo copy of reports and other details etc.
- To collect the birth and death reports from the ward and report to Corporation of Chennai within the legal time frame i.e. 21 days for birth and 21 days for death. To collect and prepare statistical reports for sending to external databases as per regulatory requirements as below: Parity data Communicable Disease Reporting Medical termination of pregnancy Acute Flaccid paralysis (AFP) Prenatal diagnostic report Renal transplantations.
- To evaluate documentation for deficiencies in the deceased patient medical files and arranging for completion of records with the cooperation of medical and nursing staff.
- To dispatch and timely retrieval of medical records required by OPD and inpatient records.
- To carryout data collection/support in data collection.
- To be capable to work in all sections of the Medical Record department and to carry out the work of that unit as per recommended procedures.
- To orient and train the Sr Attenders.
- To participate in educational programs such as seminars, workshops and conferences related to the medical record profession.
- To carry out any other duties and functions related to medical record services as instructed by the head of the department.
- To participate in educational programs such as departmental and HR training programs.
- To work in one of the three shifts as required.
- To be familiar with computers and other mechanical devices for maintaining records.
- To participate and contribute to departmental quality initiatives.
- To adhere to the safety norms of hospital and follow both patient and staff safety rules.
Location- Tamil Nadu
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