Executive/Sr. Executive - Homecare (Clinical Records / Documentation

Role & Responsibilities

• Ensure completeness and compliance of patient documentation, including assessments, care plans, nursing notes, visit records and discharge/closure records.
• Monitor consent form compliance, ensuring required consents are complete, appropriately signed and maintained.
• Conduct periodic medical record audits to identify documentation gaps and drive timely closure.
• Ensure document control for Homecare forms, formats, SOPs and checklists, including version control and withdrawal of obsolete documents.
• Monitor continuity-of-care documentation, including handovers, changes in patient condition, interventions, escalation and referrals.
• Maintain compliance trackers and dashboards and report key gaps, trends and recurring non-compliances to Nursing/Operations leadership.
• Support internal audits, quality reviews and NABH/accreditation readiness, including evidence preparation and CAPA follow-up.
• Coordinate with Nursing, Clinical, Operations and Quality teams to strengthen documentation practices and drive continuous improvement.

Preferred candidate profile

• Strong documentation and record-management skills
• Good understanding of healthcare/nursing documentation and consent processes
• Audit and compliance orientation with strong attention to detail
• Good MS Office / Excel and reporting skills
• Ability to identify gaps, trends and recurring non-compliances
• Strong follow-up and coordination skills
• Understanding of patient confidentiality and medical-record security
• Good communication and stakeholder-management skills

Qualification: Bachelor's degree in any discipline, Nursing Qualification will be preferred but not mandatory