Job Description

Job Summary:
The Medical Records Officer is responsible for maintaining, organizing, and managing patient health records in compliance with legal, regulatory, and hospital policies. The role ensures accuracy, confidentiality, and accessibility of medical records for healthcare providers, patients, and authorized entities.
Key Responsibilities:
1. Medical Records Management:

• Maintain and update electronic (EMR/EHR) and paper-based medical records.
• Ensure proper filing, indexing, and archiving of patient records.
• Retrieve and distribute medical records for patient care, audits, and legal requests.
• Verify completeness and accuracy of records, including diagnoses, treatments, and discharge summaries.

2. Compliance & Confidentiality:

• Adhere to HIPAA, GDPR, or other regional data protection laws.
• Implement hospital policies on record retention, disposal, and security.
• Handle sensitive patient information with strict confidentiality.

3. Quality Assurance & Audits:

• Conduct regular audits to ensure compliance with documentation standards.
• Identify and rectify discrepancies in medical records.
• Assist in accreditation processes (e.g., JCI, NABH) by maintaining audit-ready records.

4. Coordination & Communication:

• Liaise with doctors, nurses, and administrative staff to resolve record-keeping issues.
• Respond to requests from legal teams, insurance companies, and government agencies.
• Facilitate smooth retrieval of records for research, billing, and continuity of care.

5. Technology & Process Improvement:

• Operate EMR/EHR systems (e.g., Epic, Cerner, Meditech).
• Recommend process improvements for efficiency and accuracy.
• Train staff on proper documentation practices.