ASSISTANT, HEALTH INFORMATION MANAGEMENT SYSTEM

KPJ Selangor Specialist Hospital; Perlis; On-site; MYR 20,000 - 40,000; Full time

Job summary

KPJ Selangor Specialist Hospital is seeking a dedicated Medical Records Clerk to manage requests for medical reports, ensure proper authorisation and timely processing, and maintain strict confidentiality in line with MOH, MMC, MSQH/JCI standards and the PDPA 2010.

You will coordinate with clinicians and reception, verify documents, input data, and ensure accurate storage and retrieval of medical records for audits, wards, and A&E.

Qualifications

• Sijil Pelajaran Malaysia (SPM) or other relevant qualifications.
• Preferably at least 1–5 years of experience from any established medical organization.
• Preferably experience in hospital administration or medical records.
• Familiarity of working in HIMS / medical records.
• Familiarity with medical terminology and hospital documentation processes.
• Knowledge of PDPA 2010 and confidentiality practices.
• Detail-oriented with a focus on accuracy.
• Proficiency in Microsoft Excel and PowerPoint.
• Results-oriented mindset, with the ability to work under pressure to meet deadlines.
• Self-motivated and able to work independently.
• Strong ethics and integrity.
• Openness to learning and adapting to change.
• A collaborative and team-oriented approach.

Responsibilities

• Receive, verify, and process medical reports, medical board and copy of medical records requests.
• Check that applications have valid authorization, consent forms, identification, and payment proof.
• Liaise with clinic reception, doctors, and services to prepare and verify reports.
• Track pending reports to ensure timely completion and delivery.
• Enter charges or receive payments for report requests per hospital policies.
• Assist typing medical reports for consultants and ensure accuracy.
• Submit reports to authorized recipients after payment confirmation.
• Record all application details in manual and electronic systems.
• Ensure access controls are enforced for confidentiality.
• Guide patients and requestors on procedures and payments.
• Respond to inquiries from patients, lawyers, insurers, and government agencies.
• Scan, upload, and store reports in hospital systems.
• Retrieve patient records for clinics, wards, A&E, audits.
• Collect and return medical record folders with proper documentation.
• Process inpatient medical record documents per discharge checklist.
• Prepare records for walk-ins and upcoming appointments.
• Release medical records only to authorized personnel and maintain tracking logs.
• File and organize returned folders according to filing system.
• Repair damaged/ incomplete records and create new volume folders as needed.
• Identify duplicates and merge records per policy.

Skills

Attention to detail

Communication

Self-motivation

Education

SPM or equivalent

Tools

Microsoft Excel

PowerPoint

HIMS software

Job description

1) GENERAL DESCRIPTION

To manage and process all requests for medical reports ina timely,accurate, and confidential manner, ensuring compliance with hospital policies, Ministry of Health (MOH), Malaysian Medical Council (MMC), MSQH /JCI standards, and the Personal Data Protection Act (PDPA) 2010.

2) JOB DESCRIPTION

Main Responsibilities

• Receive, verify, and processmedical reports, medical board and copy of medical records requests from patients, next-of-kin, insurers, lawyers, and external agenciesin accordance withhospital policies and procedures.

• Check and ensure that all applications are complete with valid authorization, consent forms, identification documents, and proof of payment before processing.

• Liaise and coordinatewith clinicreceptionist, doctors, and relevantservicestofacilitatethe preparation, completion, verification, and approval of medical reports.

• Track, arrange, and follow upon pending medical reports to ensuretimelycompletion and delivery within timelines given.

• Assistin enteringcharges or receive payments for medical reports, medical board and copy of medical records requestsin accordance withhospital policies and procedures (If applicable).

• Assisttyping medical report for consultants (if applicable) and ensure that all medical reports prepared by Consultants, Medical Officers, or ad hoc personnel are processed promptly and typed accurately with minimal errors.

• Submit and distributecompleted medical reports to clinicsreceptionistor authorized recipients after confirming payment and monitor collection or delivery status.

• Gather, record, and updateall application details, including request type, payment status, processing timelines, and report completion dates, in both manual and electronic systems.

• Ensure and enforcethat only authorized personnel arepermittedto access, view, or collect medical reports, in compliance with confidentiality policies.

• Provide guidance andassistanceto patients, next-of-kin, and authorized requestorsregardingmedical report procedures, requirements, and payment processes.

• Respond promptly and professionallyto inquiries from patients, legal firms, insurance companies, and government agenciesregardingmedical report requests.

• Scan, upload, andoperatehospital systems to ensure completed medical reports are accurately stored and easily retrievable by authorized users.

• Retrieve and providepatient medical records folder upon requests via phone call or system for clinics, wards, Accident & Emergency (A&E), audits, or other authorized purposes.

• Collect, process, and returnmedical record folders from wards and clinics, ensuring all movements are accurately documented and tracked.

• Receive, verify, and process inpatient medical record documents to ensure completeness and compliance with the discharge checklist.

• Trace, prepare, and checkmedical record folders for walk-in patients and upcoming appointments to ensure readiness for clinical use.

• Issue and releasemedical records folder only to authorized personnel andmaintainand collateaccuratetracking logs (manual or electronic) for all medical records folder movements.

• File, arrange, andmaintainreturned medical record folders accurately according to the hospital’s approved filing system and numbering sequence.

• Repair and processdamaged, incomplete, or soiled records, andproducenew volume folders for bulky patient files asrequired.

• Identifyduplicate medical records and ensure the merging process is accurately executed and fully completedin accordance withhospital policies and data integrity standards.

• Ensure and checkthat all medical records are stored securely and neatly under proper environmental conditions (clean, dry, and pest-free) and ensure maintenance of facilities in a proper condition.

• Assistand liaisewith staff inlocatingor retrieving missing or misfiled medical records folder and promptlyreport and evaluatecases of loss or damage to the Head of HIMS.

Other Duties and Responsibilities

• Perform any other responsibilities assigned by immediate superior or hospital management.

3) JOB REQUIREMENT

• Sijil Pelajaran Malaysia (SPM) or other relevant qualifications.

• Preferablyat least1 - 5 years of experience from any established medical organization.

• Preferablyexperience in hospital administration or medical records.

• Familiarity ofworking in HIMS / medical records.

• Familiarity with medical terminology and hospital documentation processes.

• Knowledge of PDPA 2010 and confidentiality practices.

• Detail-oriented with a focus on accuracy.

• Proficiencyin Microsoft Excel and PowerPoint.

• Results-oriented mindset, with the ability to work under pressure to meet deadlines.

• Self-motivated and able to work independently.

• Strong ethics and integrity.

• Openness to learning and adapting to change.

• A collaborative and team-oriented approach.