Health informatics Technician

Job Description

Responsible for carrying-out all procedures as they relate to the organization of all patient medical records.

Responsible for Assembly and Analysis (OP/IP), loose reports collecting and filing, creating new folders after the discharge of the patient. To ensure that each in-patient medical records contains necessary documentation, reports, tests results, or other required elements as per departmental policy based on CBAHI and JCIA standards.

Retrieve record as requested.

Responsible for notifying all physicians of their incomplete medical records monthly to comply with hospital policy. All queries from Physicians are referred to this policy.

Proper file maintenance has to be maintains in the master record filing area.

Auditing of files will be carried-out.

Is able to work independently with minimal direct supervision.

Major Duties and Responsibilities

Outpatient Record Retrieval / Filing

• Retrieves all medical records upon request (walk-in patients and ER patients)
• Retrieves booked outpatient appointment for next day and filing back the returned patients record.
• Reviews and assembles Medical records after retrieval
• Prepares medical record folders for new patients.
• Inserts all incoming reports throughout each shift to prevent backlog.
• Maintains all shelving areas in accurate terminal digit order by periodically performing file audits.
• Complies with the departmental policies and procedures in addition to the general hospital’s policies governing all staff members.
• Routing the records to the outpatient and inpatient departments when it’s urgently needed for the patient care.
• Maintains accurate, neat files in a timely manner.
• Maintains confidentiality, security and personal privacy of all patient information and files.
• Places records on appropriate shelving area, i.e. permanent filing area, incomplete, coding and etc.
• Perform other duties as required.

Assembly and Analysis

• Responsible for collection of discharged medical records not forwarded to HIM Department within 24 hours of discharge.
• Assemble the unorganized document according to the standard assembling order (CBAHI and JCIA standard) of the discharged patient’s records.
• Analyze the medical record file for missing documents as per policy and indicate by flags.
• Assign deficient record to every physician responsible for dictating Reports.
• Maintains accurate, neat files in a timely manner.
• Maintains confidentiality, security and personal privacy of all patient information and files.
• Enter and maintains the computerized Medical Record Deficiency system.
• Work is conducted in a professional manner maintains patient / staff confidentiality when required.
• Performs other applicable tasks and duties assigned within the realm of the employee’s knowledge, skills and duties.
• Contact the Concerned physician and inform them about their deficient files.

Physician Completion

• Retrieves the delinquent records list from the computer with physician ID# and name.
• Retrieves all incomplete medical records as requested.
• Notifies physicians of their incomplete medical records by sending reminder letter weekly (first day) to comply with the hospital policy.
• Forward the lost notification at the end of the third week about the delinquent record holder physician name to the administration.
• Maintains the computerized medical record deficiency system by updating and clearing the medical records and respective physician deficiency profile as physicians complete their records.
• Maintains confidentiality, security and personal privacy of all patient information and files.
• Maintains accurate, neat files in a timely manner.
• Re-analyzes all medical records determined to be completed before forwarding to the clinical coding section for discharge analysis.
• Obtains counter-signature from consultants before first week of every month.
• Submits a weekly and monthly report on the number of delinquent records by physician department and type of deficiencies, i.e. signature, H & P’s, operation notes and discharge summaries as per policies.
• Performs applicable tasks and duties assigned within the realm of the employee’s knowledge, skills and duties.

General

• Participates in on-going education program developed by the department, e.g. department policies and procedures, Fire and Safety, Risk Management, Environmental control.
• Participates in Monthly meeting to ensure that all the staff completing their job description according to the policy and procedure of the department and discussing current issues to keep the quality to the patient care services.
• Complies with hospital dress code.

Reporting to

• HIM Coordinator/Director/Head

Qualifications:

• Diploma in Medical Record Science / Technology

Experience:

• At least three (3) years’ experience working in Medical record department performing Technical tasks.

Special requirements/skills:

• Fluency in verbal and written English.
• Must possess complete familiarity with required medical record documentation, medical terminology, Anatomy, Physiology and Pathology.
• Must possess thorough comprehension of the HIS system as it relates to the HIM department and utilize that knowledge for practical applications.
• Ability to operate computerized health information system as required by departmental functions.
• Ability to understand diverse documentation styles.
• Exhibits professionalism and excellent interpersonal communication skills.