Reporting To: Emergency Physician
Position Summary: Plan, organize and direct the activities, work load and special projects within the Department to meet standards set by Management or other accreditation requirement.Ensure that patient records are kept secure according to regulatory legislation, to protect patient confidentiality.Be familiar with software programs used to maintain records, only release medical information according to regulations.Coordinate department activities and performance improvement.
Duties and Responsibilities:
1. Help to ensure the privacy, safety and security of records, including release of information only to authorized individuals, including clinicians treating the patient, the patient or others as required by law.
2. Propose and recommend departmental policies and procedures where applicable.
3. Implement effective data storage methods and retrieval systems for patient medical records.
4. Ensure proper filing, retrieving and tracking system of the patient medical records.
5. Ensure all active and inactive files are segregated, update computer inactive status and record in Inactive Record Book.
6. Assist to perform data entry, medical coding and resolving missing information in patient records.
7. Work closely with the medical staff to assure the smooth completion of medical records.
8. Assist in the care and maintenance of department equipment and supplies.
9. Help to assure timely utilization of the hospital services to meet the admission and discharge needs of all patients in the most effective manner.
10. Help to process charge of reports such as payment through cheque or bill amended request.
11. Responsible for the hiring, department specific orientation, training and performance review of Assistants working in the department.
12. Prepare roster and maintain leave record for Medical Record staff.
13. Supervise and ensure staff performs their duties in accordance with the hospital and department policies.
14. Provide education opportunities for staff. Demonstrate an ongoing commitment to continuing professional development and education.
15. Direct staff in the areas of coding and reimbursement, transcription, resource utilization, and statistical reporting (ICD Coding) for national healthcare issues, trends and research, release of information and medical filing.
16. Responsible to the abstracting functions reportable to the Regional Chief Executive Officer
(RCEO)/ Chief Executive Officer (CEO), Management and Ministry of Health.
17. Compile ICD coding for all discharge, monthly mortality and morbidity report, and monthly inpatient returns statistics to the RCEO/CEO and copy to the Ministry of Health.
18. Oversee the budget; participate in management meetings and committees.
19. Perform administration duties, such as;
* maintain Death Record
* make available Birth and Death Certificate Forms from registration department.
* make available any necessary form from district health office or state health department.
* maintain record of communicable and non-communicable diseases.
20. Attend relevant training and courses to meet own development needs and those of the department in accordance with the hospital's objectives.
21. Observe and be conversant with all statutory requirements, rules and legislation related to the job.
22. As and when required, to attend meeting with Government agencies and department.
23. Perform Quality Indicator for the department as required by Management or accreditation standard.
24. Perform other related duties as arranged or requested by authorized others.
Education and Requirements: Bachelor in Health Information management/records management or a related healthcare field.Need management and organizational skills.Be familiar with medical coding and medical terminology.Strong computer skills. Special Demands: Interpersonal and communication skills.Possess good managerial and leadership, negotiation, communication andInterpersonal relationship skills and good judgment. Eye for detalls and accuracy. Trustworthy, ethical and discreet.