Medical Record Clerk

Pantai Hospital Penang; Bayan Lepas; On-site; MYR 60,000 - 90,000; Full time

Job summary

Pantai Hospital Penang is seeking a dedicated Medical Records professional to manage daily operations, ensure compliance with national acts and accreditation standards, and support documentation quality across wards and departments.

The role includes chart reviews, staff training, and maintaining orderly filing while coordinating monthly rosters and quality improvement activities within the Medical Records Department.

Responsibilities

• Documents, implements and reviews policies and procedures in liaison with the Medical-Record-In-Charge.
• Organizes, directs, controls and evaluates daily operations; develops and implements a quality assurance system to meet medical records management and policy requirements.
• Ensures medical records contents are efficiently handled by Ward Clerks who provide clerical support to Nursing Staff in all wards; includes filing discharge folders and incomplete discharge summaries by consultants.
• Ensures compliance with the Private Healthcare Facilities and Services Act and directives from The Ministry of Health, Malaysia and hospital accreditation standards.
• Maintains efficient filing and retrieval of medical records to provide excellent service to Doctors, wards and other departments.
• Oversees smooth operations of Medical Records department functions under the C-plus system and One Stop Center; handles queries from Consultants, Sister on call, Staff Nurse, Clinic Assistant.
• Ensures timely submission of statutory requirements and notifications to the Ministry of Health.
• Performs chart reviews with the Chart Review Committee and conducts compliance audits for initial doctor assessments and discharge summaries.
• Maintains competency and provides training to new staff in all department functions and discharge diagnosis coding (ICD-11).
• Evaluates accuracy of discharge diagnosis coding and procedure codes.
• Maintains neat and orderly filing and storage in compactors and shelves.
• Responsible for monthly staff roster and quality improvement activities in the MR Department.
• Compiles monthly statistics and reports to ensure on-time submissions to Administration and related departments.
• Ensures achievement of accreditation and certification standards for medical records services.
• Provides in-service training for existing and new staff as assigned by the Medical Record Officer-In-Charge.
• Performs other appropriate tasks and duties as needed and participates in community service when required.

Job description

• 1. Documents, implements and reviews policies and procedures i n liaison with the Medical-Record-In-Charge.
• 2. Organizes, directs, controls and evaluates daily operations; develops and implements quality assurance system to meet medical records management and policies requirements.
• 3. Ensures that medical records contents are efficiently handled by Ward Clerks who provides clerical support service to Nursing Staff in all wards. This includes ward clerk dispatch discharge folders, uncompleted discharge summary by consultants.
• 4. Ensures medical records information related to patient charts, records and documents are i n compliance with Private Healthcare Facilities and Services Act and Directives and Guidelines from The Ministry of Health, Malaysia and all Hospital Accreditation Standards.
• 5. Ensures efficient filing and retrieving of medical records to provide excellent services to Doctors, wards and other relevant departments when requested.
• 6. Ensures smooth operations of medical records department functions provided under the C - plus system and operation Medical Records as One stop center. This includes replying to all queries by requestors - Consultants /Sister on call / Staff Nurse/Clinic Assistant. - Communication skills.
• 7. Ensures timely submission of all statutory requirement and notifications to the Ministry of
• 8. Performs chart review in collaboration with the Chart Review Committee. -Compliance audit for Doctor Initial Assessment and Completeness of Discharge Summary
• 9. Maintains high level of competency and provide training to new staff i n all functions and procedures of the department and discharge diagnosis coding.
• 10. Evaluates, assesses, and monitors the accuracy of discharge diagnosis coding (ICD 11) and procedure codes.
• 11. Ensures good standard i n filing of contents of medical records.
• 12. Ensures neat and orderly filing system of medical records in the compactors and shelves.
• 13. Responsible for monthly staff roster.
• 14. Responsible for the quality improvement activities of the Medical Record Department.
• 15. Compiles monthly statistical reports (MSQH/MQM/Form (PS201)), census, data, information etc to ensure on-time submission to Administration Department and other authorized relevant departments.
• 16. Ensures achievement and compliance t o accreditation and certification standards for medical. record service.
• 17. Provides in-service training for existing and new staff of the department as and when assigned by Medical Record Officer-In-Charge.
• 19 Perform others appropriate tasks and duties assigned with the realm of the employee's knowledge and abilities
• 20. Participates in Hospital community service when required.
• 21. Involves in Quality Improvement activities at departmental level.
• 22. To assist as and when the need arises in the arrangement of Community Service projects and other projects conducted by the Hospital.
• 23. To undertake any other duties as delegated by the immediate superior from time-to-time eg. Medical Records projects.