Medical Records - Incharge | Sahyadri Hospitals | Nagar Road

Job Description

To interpret, organize and direct a sound plan of organization and communication system in accordance with established policies and objectives of the department. To facilitate error free departmental procedures by counter verifying all the inpatient records, ICD coding entries and conducting medical record audits with the medical audit team. To plan the required MIS format & interpreting the data received from the MIS in order to provide written reports on all Medical Record related activities of the respective unit. To ensure that the content of the discharge summary is accurate and tallies with the history sheet & the treatment given. To adopt measures to ensure that the confidentiality of the patients files is maintained. To document the adverse events found in the file and reporting to the same to the management by maintaining the confidentiality. To be responsible for adopting measures that ensures security of the patient files. To supervise and controlling on the retrieval process of the patient files. To conduct periodic audit of the department to monitor the adherence to the policies & protocols, and to adopt corrective action in case of any noncompliance. To do the verification & accounting of the stock of consumables used in the medical records department as a part of inventory management. To prepare, maintain and submit various reports as per requirements from local government bodies. To represent the medical records department in various committees and face the quality accreditation audits like ISO, NABH, and JCI etc. To assist the Medical Director in evaluation and revision of policies and standards of practice, procedures and regulations of medical records department in order to meet changing needs. Any other work assigned by the management. To prepare the annual medical records department budget in coordination with the Medical Director & Unit Head for the respective unit. To be responsible for overall QA program and the tracking of Key Performance indicators. To perform medical documentation audit The list of duties and responsibilities mentioned above is indicative, not exhaustive. BAMS/BHMS preferred.