Medical Record Officer

Role & responsibilities

• Maintain and manage medical records of patients accurately and systematically.
• Ensure proper collection, verification, filing, indexing, and retrieval of patient records.
• Maintain inpatient and outpatient medical records as per hospital policies.
• Ensure completeness of records, including case sheets, discharge summaries, investigation reports, consent forms, and treatment documentation.
• Coordinate with doctors, nursing, billing, and other departments for missing or incomplete documentation.
• Ensure proper confidentiality and security of patient medical information.
• Manage record retention, storage, archiving, and disposal as per applicable hospital policies and regulations.
• Maintain and monitor MRD registers, statistics, and daily/monthly reports.
• Support preparation of hospital statistics and MIS reports related to patient records.
• Ensure proper coding, indexing, and classification of medical records; knowledge of ICD-10 coding is an advantage.

Preferred candidate profile

• Qualification: Diploma/Degree in Medical Records / Health Information Management or equivalent.
• Experience: 815 years of relevant experience in a Medical College / Teaching Hospital.
• Strong knowledge of Medical Record Department (MRD) operations and documentation standards.
• Good knowledge of hospital information systems (HIS/HMIS) and MS Office.
• Knowledge of ICD-10 coding, indexing, classification, and medical record statistics preferred.
• Experience in preparing MRD MIS, hospital statistics, and regulatory reports.
• Exposure to NABH/NMC inspections, audits, and accreditation documentation will be an advantage.
• Strong understanding of patient confidentiality and medical record retention policies.
• Good team management, coordination, and communication skills.
• Candidates with experience in a large teaching hospital/medical college with high patient volume will be preferred.