Role & Responsibilities of Medical Record Officer As Per National & International Guidelines

Medical records officer is responsible for maintaining and securing all written and electronic medical records within a Hospital's medical records department.

They also ensure that information contained in the record is complete, accurate and only available to authorized personnel of the hospital. Other duties include overseeing personnel for the entire department, which can include medical record technicians, medical coding specialists and file clerks. Medical records officer also collect data for Quality Indicators and medical research.

Medical records officer supervises, guide and motivate their all team members while implementing departmental policies.

Qualification Criteria for Medical records officer is:

Graduate in any specialization and at least one-year diploma in Medical Record Management

Skills Required for Medical records officer are:

Data analytics Time Management, Attention to Information, Knowledge of Quality Standards, Professionalism, Productivity, Thoroughness, Coordination, Deadline-Oriented, Internal Communications, Reporting Skills.

Responsibilities of a Medical Record Officer:

1.    Planning, organizing and coordinating Inter and Intradepartmental tasks.

2.    Supervision of day to day activities of MRD.

3.    Pre-assemble all patients’ medical records and deliver to providers on time.

4.    Management of court cases relating to medical records.

5.    Complying with statutory compliance.

6.    Preparing duty rosters and allocating work to personnel working in MRD.

7.    Identification and acquisition of resources for MRD department.

8.    Updating the technology as per the strategic changes in the organization and the legal and other regulatory requirements.

9.    Generation of reports and contributing to various other data base, both internal and external as per the requirements and agreed policy.

10. Accepting and verifying the request of various parties and agencies for retrieval of data and patient records.

11. Day to day administration and trouble-shooting as and when required.

12. Responding to all agencies, groups and individuals who interact with the MRD department.

13. To Ensure ICD 10 coding for every patient’s diagnosis at the IPD level for all patients Files.

14. To maintain and improve Quality of MRD services by:

·       Color Coding of Medical Record Files

·       Following SOPs that have been laid down by Hospital.

·       Actively participation in meetings.

15. Participating in quality improvement activities including audits, development and implementation of protocols, accreditation requirements etc.

16. To take part in all department meetings.

17. Ensure Daily Audit Work of Active File and Medical Record Files

18. To maintain privacy & confidentiality of the patient records.

19. To keep the medical records in the safe custody & complete all the time.

20. To make the records available as and when required.

21. To interact & ensure with other locations for procuring necessary records.

22. To check the records for accuracy & completion within defined time-scales.

23. To file records systematically with the standard indexing practice.

24. To follow up with the physicians/ nurses for Medical Record completion on priority.

25. To communicate with the government departments/ officials for medico legal requirement on an ongoing need basis.

26. To assist in generation of data and reports as per requirements of the system.

27. To Ensure Submission of Daily/ weekly/Monthly Reports for all government departments/ Agencies for official purpose and list of department and agencies are given below along with Periodicity of data submission:

·      The notifiable diseases which are notified to CMO Office & Nagar Nigam office on monthly basis.

·    Birth registration is being done by filling and sending a death report on the approved form to the Birth Registration, Nagar Nigam.

·     Death registration is being done by filling and sending a death report on the approved form to the Birth & Death Registration, Nagar Nigam.

28. Ensure Monthly Report of Some Quality Indicators which are Defined by NABH:

Written by:

Dr. Praveen Bajpai

Director of Ingenious Healthcare Consultants Pvt. Ltd.
Founder of Skill Sathi

MBA in Hospital administration, PG Diploma in Quality Accreditation, PG Diploma in Medico Legal System, M. Phil in Hospital Mgmt. from BITS Pilani, P.hD in Management, Certified NABH Auditor, Certified NABL Auditor, Certified Auditor for Clinical Audits, Green Belt in Six Sigma, Certified in Hospital Infection Control Practices, Certified trainer for International Patient Safety Goals, Certified Auditor for JCI 7th Edition Standards 

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