Maintains record of patient care by compiling, reviewing, and filing documentation of patient's condition, treatment, and health outcome.
Maintains medical records operations by following policies and procedures; reporting needed changes.
Initiates medical record by searching master patient index; identifying existing patient records or need to assign a new number; interacting with registration areas and physician's offices for information verification; processing or creating the record folder.
Ensures medical record availability by routing records to admissions and emergency departments, physicians, and other authorized hospital staff; maintaining chart location systems.
Completes medical record by reviewing information; notifying health care providers of record deficiencies; tracking outstanding records.
Resolves medical record discrepancies by collecting and analyzing information and making necessary corrections.
2. Medical Data Coding
Maintains historical reference by abstracting and coding clinical data, such as diseases, operations, procedures, and therapies, using standard classification systems; filing documents.
Consult classification manuals to locate information about disease processes.
3. Privacy & Legal Compliance
Maintains the stability and reputation of the hospital by complying with legal requirements.
Maintains patient confidentiality and protects hospital operations by keeping information confidential; following release-of-information protocols.
Releases information to persons or agencies according to regulations.
4. Reporting & Statistics
Prepares statistical reports by collecting and summarizing medical care and census information, surgery performed, and use of hospital beds.
Prepares narrative reports or graphic presentations of information, such as tumor registry data for hospital staff or researchers.
Compiles census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.
5. Information Requests & Department Oversight
Provides medical record information by answering questions and requests from patients, staff, courts, insurance companies, and government agencies.
Resolves or clarifies codes or diagnoses with missing or unclear information by consulting with doctors or participating in team meetings.
Retrieves patient medical records for physicians, technicians, or other medical personnel.
Plans, develops, or operates record indexes or systems to collect, store, or analyze health information.
Compiles and maintains patient medical records to support treatment documentation, research, or care improvement.
Manages the medical record department or supervises clerical staff.
Develops in-service educational materials.
Education - Diploma in Medical Records Technology
Experience - 1 - 5 years
Job Type: Full-time
Pay: ?18,000.00 - ?28,000.00 per month
Work Location: In person
Beware of fraud agents! do not pay money to get a job
MNCJobsIndia.com will not be responsible for any payment made to a third-party. All Terms of Use are applicable.