Medical Chart Controller

JOB DESCRIPTION
Designation: Medical Chart Controller
Section/Department: Health Information Management
Reporting to: HIM Supervisor
Responsible for/Reporting Staff:
Purpose and Scope of the Job:
Under direct supervision, Medical Chart Controller is responsible to review
the patient chart to ensure documents and documentation are complying to
hospital policy.
Main Duties and Responsibilities/Performance Standards
* Daily monitoring of work queues to evaluate electronic medical records are completed on a quantitative and qualitative basis in timely manner.
* Evaluate patient charts for document deficiencies and review to ensure all patient encounter has essential documents are completed and signed by the Physician based on hospital guidelines
* Analyze patient chart to confirm documented clinical notes are complying with hospital policy.
* Preparation of Letters to physician as a reminder to complete the deficient charts.
* Preparation of reports (Generating, Analyzing, and Designing) as and when required related to document deficiency and documentation compliance
* Electronically transcribes clinical note (discharge summary) whenever it is requested by the Sick Leave Office / Customer Service Department.
* Ensuring confidentiality of information contained in patient's chart and guides against misuse of information contained therein
* Follow established departmental policies, procedures, and objectives, continuous quality improvement objectives, and safety, environmental, and/or infection control standards
* Maintain patient's confidentiality, security and integrity of the electronic medical record and ensure hospital policies are complied.
* Performs miscellaneous job-related duties as assigned by the Direct Reporting Authority.
* Ensures quality and patient safety practices are followed.
* Provides or promotes patient and family-centered care.
* Promotes inclusive health by providing equitable and accessible care to patients and families with special needs.
Qualifications, Competencies and Skills
Education : Degree/ Diploma related with Nursing or Bachelor degree in
Medical Records Management
Experience : Previous experience in health information management or
related field
Language : Proficiency in English Language
Computer Proficiency : Computer literacy - highly skilled in Microsoft
Office
Performance Competencies
* Ability to work independently and demonstrate problem-solving skills.
* Ability to organize work, set priorities and analyze data accurately.
* Must have good time management skills
* Excellent communication (Verbal and written), organizational skills and attention to detail
* Multi-task oriented with the ability to handle complex issues while providing excellent service to all including physicians, clinical staff, patients, reviewers, etc.
* Accomplishing tasks by accurately checking processes; being watchful over a period of time.
* Excellent in computer skills - Microsoft Office
Principle Working Relationships and Remarks
* Medical Records Auditor
* Quality Assurance Officer
* Archiving Technician
* Medical Records Staff