Medical Records Officer ( MRD )

Job Description

Job Summary: The MRD Executive is responsible for the accurate, confidential, and timely handling of all medical records within Ahad Mult speciality Hospital. This includes collecting, organizing, coding, storing, retrieving, and safeguarding patient records in compliance with legal, ethical, and hospital policies, including NABH standards. Key Responsibilities: ✅ Medical Records Management Collect patient files from all departments (OPD, IPD, ICU, OT, etc.). Maintain and organize physical and/or digital records of admissions, treatment, diagnostic reports, and discharge summaries. Ensure all records are complete, updated, and properly indexed. ✅ Coding and Data Entry Assign ICD-10 codes for diagnoses and procedures where applicable. Enter patient data into Hospital Information System (HIS) or other record management software. Maintain statistics on patient demographics, disease profiles, mortality, and morbidity. ✅ Confidentiality & Security Ensure the confidentiality of all patient health information as per medical ethics and hospital policies. Restrict access to authorized personnel only and follow secure handling protocols. ✅ Discharge File Auditing Verify discharge summaries, investigation reports, and consent forms are complete. Ensure compliance with NABH/ISO documentation requirements. Maintain discharge file checklists and audit forms. ✅ File Retrieval & Record Requests Retrieve records promptly upon authorized requests from doctors, departments, or legal authorities. Maintain logs for file movement and requests. ✅ Compliance & Reporting Support in preparing reports for audits, medico-legal cases, and quality departments. Assist in maintaining NABH-compliant MRD documentation systems. Qualifications: Graduate in any stream (preferably B.Sc./BBA/Health Information Management) Diploma or Certification in Medical Records or Health Information Management preferred 1–3 years of experience in hospital MRD or health records management Key Skills: Excellent organizational and filing skills Attention to detail and data accuracy Familiarity with ICD coding, HIS, or EMR systems Basic knowledge of NABH/JCI documentation norms Confidentiality, integrity, and teamwork