Medical Record Incharge

Sahrudaya Health Care; Bengaluru; On-site; INR 250,000 - 400,000; Full time

Job summary

Sahrudaya Health Care seeks a Medical Record Technician (MRT) to manage and safeguard patient health records within the hospital. You will organize, code, and maintain both physical and electronic records, ensuring accuracy and confidentiality across departments.

You will verify patient demographics, support data entry into the HIS/EMR, and collaborate with doctors and nurses to collect complete documentation for discharge and audits. Quality and security are paramount in this role.

Qualifications

• Maintain, organize, secure, and retrieve patients' medical records with accuracy and confidentiality.
• Ensure documentation is complete and properly filed in both physical and electronic records.
• Assist in coding review and record retrieval for audits where applicable.

Responsibilities

• Maintain patient medical records across departments and ensure proper filing.
• Verify demographics and record numbers to prevent duplicates.
• Enter patient data into the hospital information system accurately.
• Coordinate with clinicians to obtain missing documents for discharge records.
• Support confidentiality and access controls for patient information.
• Prepare records for medical-record audits and reviews.

Skills

Medical record management

Data entry

Confidentiality

Coordination with departments

EMR proficiency

Education

Diploma in Medical Records

Tools

Hospital Information System

EMR software

Job description

Role & responsibilities

ChatGPT said:

Roles & Responsibilities of a Medical Record Technician in a Hospital

A Medical Record Technician (MRT) is responsible for maintaining, organizing, securing, and retrieving patients medical records while ensuring that documentation is accurate, complete, and confidential.

1. Medical Record Management

• Create and maintain patient medical records.
• Collect and organize medical documents from different hospital departments.
• File and retrieve records efficiently.
• Ensure records are complete, accurate, and properly arranged.
• Maintain both physical and electronic medical records.

2. Patient Registration & Identification

• Verify patient demographic and identification details.
• Create medical record numbers and maintain accurate patient identification.
• Avoid duplicate medical records.
• Update patient information when required.

3. Documentation & Data Entry

• Enter patient information accurately into the hospital information system.
• Check medical records for missing or incomplete documentation.
• Ensure reports, discharge summaries, investigation results, and treatment records are properly filed.
• Assist in maintaining standardized medical documentation.

4. Discharge Record Management

• Collect and organize records after patient discharge.
• Check discharge files for completeness.
• Coordinate with doctors and departments for missing documents.
• Prepare records for medical record review and coding, where applicable.

5. Medical Coding & Classification

• Assist with assigning appropriate diagnosis and procedure codes according to applicable coding standards and hospital policies.
• Review documentation to support accurate coding.
• Identify discrepancies and coordinate clarification with the concerned department.

6. Record Retrieval

• Retrieve medical records for doctors, nurses, departments, audits, insurance claims, and authorized requests.
• Track records issued to different departments.
• Ensure timely return and proper filing of records.

7. Confidentiality & Privacy

• Maintain strict confidentiality of patient information.
• Release medical records only to authorized persons according to hospital policy and applicable law.
• Protect records from unauthorized access, loss, damage, or alteration.

8. Statistics & Reporting

• Collect and compile hospital statistics such as:
• Admissions
• Discharges
• Deaths
• Length of stay
• Outpatient visits
• Bed occupancy
• Prepare routine medical-record reports for hospital management.
• Support data collection for audits and accreditation.

9. Quality & Audit

• Conduct medical record completeness checks.
• Identify missing signatures, reports, diagnoses, or other required documentation.
• Participate in medical record audits.
• Support quality improvement and hospital accreditation activities.

10. Coordination With Hospital Departments

• Coordinate with doctors, nursing staff, laboratory, radiology, billing, insurance, and other departments.
• Follow up on incomplete or missing documentation.
• Support smooth flow of patient information within the hospital.

11. Electronic Medical Records (EMR)

• Maintain electronic patient records accurately.
• Perform data entry and record updates in the hospital information system.
• Assist users with basic medical-record-related system issues.
• Follow appropriate access-control and data-security procedures.

12. Legal & Retention Responsibilities

• Maintain records according to hospital retention policies and applicable regulations.
• Ensure proper documentation for medico-legal cases.
• Preserve records required for legal, insurance, audit, or regulatory purposes.
• Assist with authorized release of records and medical information.

Preferred candidate profile

* Must have experience as MRD incharge.

* Preferring candidate with immediate joiner