Medical Records Technician/ IN charge

Role & responsibilities

• Responsible for overall supervision, control and effective functioning of Medical Records Department.
• Ensure timely retrieval of Medical records as and when required.
• Ensure proper upkeep of Medical records.
• Generating Monthly accurate statistics.
• Timely submission of Birth/ Death certificate.
• Ensuring that ICD coding is done properly.
• Ensuring statutory/ statistical returns accordingly to the respective Department in time.
• Any other work assigned by the management from time to time.

Preferred candidate profile

• The Medical Records Technician is responsible to the Hospital Administrator.
• To ensure that the department works efficiently and smoothly.
• Issue and receive OP Files
• To prepare admission and discharge report everyday.
• To assemble IP files according to the IP assembling format (FF-MRD-10)
• To File Lab Reports and Medical Records.
• Before filing, to ensure that the records are complete in all matters. If not, it is his duty to get the deficiency cleared by the concerned person.
• To complete or get it completed, various columns of Face Sheet (Admission to discharge sheet) of the patients case file.
• To maintain a MRD record register, where in to enter the files received in order of MRD (IPD) numbers.
• To verify that the MRD has received files of all the discharge patients. If the file of a discharge patient is not received, to find out the reason and search for the missing file. If not traced, the matter should be brought to the knowledge of Administrator. The file has to be traced and if lost, an entry should be made in the MRD register giving actual reasons.
• To prepare a list of all in-house transfer from one ward to other.
• To prepare discharge analysis
• To compile the following statistics:

a) Occupancy per day.

b) Total hospital days – gender wise

c) Gender wise distribution of discharges

d) Unitwise distribution of discharges and deaths

e) Georgraphical distribution of discharged patients.

f) Average length of stay of patients

g) Any other statistics required by the administrator.

• To complete the Central Admission and discharge Register, maintained at the Admission Desk or at the main Reception, in regard to diagnosis and result of treatment.
• To be aware of the WHO International classification of diseases and to code the disease of discharge patients on that basis.
• To Prepare Birth/ Death information
• To be responsible for completing “Birth and Death Register”, complete the various forms required to send information to corporation / Health authorities.
• To compile the statistics of Birth and Death for the management.
• To keep the records and department neat and clean always.
• To receive all MLC Registers and Injury Register from respective departments, when they are complete for storing them, for at least 3 years.
• To pay particular attention to see that all MLC records are complete.
• To be responsible for providing all assistance to police officers in the form of requirement of Injury Report, MLC Investigation Reports, in original.
• To be responsible to attend court and produce required records.