ASSISTANT, HEALTH INFORMATION MANAGEMENT SYSTEM

DAMANSARA SPECIALIST HOSPITAL 2; Petaling Jaya; On-site; MYR 30,000 - 45,000; Full time

Job summary

DAMANSARA SPECIALIST HOSPITAL 2 is seeking a dedicated individual to manage patient medical records, ensuring accuracy, proper documentation, and efficient retrieval across departments. Ideal candidates should possess Sijil Pelajaran Malaysia (SPM) or relevant qualifications, and have 1-5 years of experience in a medical organization.

The successful applicant will work closely with medical staff, ensuring compliance with hospital policies regarding patient records. Basic IT knowledge and familiarity with medical record systems are essential for this role.

Qualifications

• 1-5 years of experience in an established medical organization preferred.
• Familiarity with HIMS / medical records and filing systems is advantageous.

Responsibilities

• Manage retrieval and documentation of patient medical records.
• Ensure accurate processing of medical records from various departments.
• Liaise with medical staff regarding documentation issues.

Skills

Detail-oriented

Accuracy focus

Basic IT knowledge

Education

Sijil Pelajaran Malaysia (SPM) or relevant qualifications

Job description

This role manages patient medical records, ensuring accurate retrieval, documentation, and distribution across various hospital departments.

Responsibilities

• Retrieve and provide patient medical records notes upon requests via phone call or system for clinics, wards, Accident & Emergency (A&E), audits, or other authorized purposes.
• Process and receive medical record notes 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.
• Issue and release medical records notes only to authorized personnel and maintain and collate accurate tracking logs (manual or electronic) for all medical records notes movements.
• File, arrange, scan, index, and maintain returned medical record notes accurately.
• Identify duplicate medical records and ensure the merging process is accurately executed and fully completed in accordance with hospital policies and data integrity standards.
• Ensure that all medical records are stored securely and neatly under proper environmental conditions (clean, dry, and pest‑free) and maintain facilities in a proper condition.
• Assist and liaise with staff in locating or retrieving missing or misfiled medical records notes and promptly report and evaluate cases of loss or damage to the Head of HIMS.
• Gather and distribute reports on notification of infectious diseases to the MOH via e‑mail/fax or through the e‑Notification system within the stipulated time (if applicable).
• Gather, collect, and dispatch the external form from the nearest JPN branch within the stipulated time.
• Indent and collect the external form from the nearest JPN branch to ensure availability.
• Liaise and communicate with medical practitioners to clarify incomplete, uncertain, or unclear documentation in patient medical records.
• Assist in assigning ICD and external cause code / procedure codes for all inpatient cases based on discharge diagnoses, in accordance with ICD regulations for statistical and reporting purposes.
• Liaise with Information Technology (IT) services for change request via the system to register new ICD code in the system.

Qualifications

• Education: Sijil Pelajaran Malaysia (SPM) or other relevant qualifications.
• Experience: Preferably at least 1‑5 years of experience from any established medical organization.
• Knowledge & Experience: Familiarity working in HIMS / medical records; familiarity with filing systems (terminal digit, straight numeric, etc.) preferred; basic IT knowledge for Hospital Information System (HIS) use.
• Skills & Competencies: Knowledgeable and committed to job responsibilities; detail‑oriented with a focus on accuracy.