Job Description: Medical Records Clerk in Maternal Health Care & Child Health Care Hospitals

A medical records clerk in maternal health care and child health care hospitals is responsible for maintaining and organizing patient medical records in an accurate and efficient manner. They play a crucial role in ensuring the smooth functioning of the hospital by managing patient information and facilitating effective communication between healthcare providers.

Responsibilities:

1. Record Management: Maintain and update patient medical records, including demographic information, medical history, test results, diagnoses, treatments, and other relevant information.

2. Data Entry: Enter patient information into the hospital’s electronic health record (EHR) system accurately and in a timely manner.

3. File Management: Organize and file physical medical records, ensuring they are stored securely and can be easily retrieved when needed.

4. Record Retrieval: Retrieve patient records as requested by healthcare providers, ensuring confidentiality and adhering to hospital policies and procedures.

5. Record Maintenance: Ensure the accuracy and completeness of patient records by regularly reviewing and updating information, including any changes in treatment plans or medications.

6. Release of Information: Process requests for the release of medical records, ensuring compliance with legal and ethical guidelines, and maintaining patient confidentiality.

7. Quality Assurance: Conduct regular audits of medical records to identify any discrepancies or errors, and take appropriate measures to rectify them.

8. Collaboration: Collaborate with healthcare providers, nurses, and other hospital staff to ensure accurate and timely documentation of patient care.

9. Training: Provide training and support to healthcare providers and staff on proper documentation practices and the use of the hospital’s EHR system.

10. Compliance: Ensure compliance with relevant laws, regulations, and accreditation standards related to medical record keeping and patient privacy.

Qualifications:

1. Education: High school diploma or equivalent. Additional certification or training in medical records management is preferred.

2. Work Experience: Previous experience working in a healthcare setting, preferably in medical records management or a related role.

3. Knowledge: Familiarity with medical terminology, EHR systems, and HIPAA regulations. Proficiency in computer skills and data entry.

4. Attention to Detail: Strong attention to detail and accuracy in maintaining and organizing patient records.

5. Organizational Skills: Excellent organizational and time management skills to handle multiple tasks and prioritize work effectively.

6. Communication Skills: Effective verbal and written communication skills to interact with healthcare providers, staff, and patients.

7. Confidentiality: Ability to maintain patient confidentiality and adhere to ethical standards in handling sensitive medical information.

8. Problem-Solving: Strong problem-solving skills to identify and resolve issues related to medical records management.

9. Teamwork: Ability to work collaboratively with a diverse team of healthcare professionals to ensure efficient record management.

10. Adaptability: Flexibility to adapt to changing technologies, procedures, and regulations in the field of medical records management.