- Location
- DAMANSARA SPECIALIST HOSPITAL 2, Malaysia
- Type
- Full-time
- Department
- Healthcare
- Experience
- 1+ years
- Source
- Workday
Description
Job Description:
- Retrieve and provide patient medical records notes upon requests via phone call or system for clinics, wards, Accident & Emergency (A&E), audits, or other authorized purposes.
- Process, and received medical record notes from wards and clinics, ensuring all movements are accurately documented and tracked.
- Receive, verify, and process inpatient medical record documents to ensure completeness and compliance with the discharge checklist.
- Issue and release medical records notes only to authorized personnel and maintain and collate accurate tracking logs (manual or electronic) for all medical records notes movements.
- File, arrange, scan, index and maintain returned medical record notes accurately.
- Identify duplicate medical records and ensure the merging process is accurately executed and fully completed in accordance with hospital policies and data integrity standards.
- Ensure and check that all medical records are stored securely and neatly under proper environmental conditions (clean, dry, and pest-free) and ensure maintenance of facilities in a proper condition.
- Assist and liaise with staff in locating or retrieving missing or misfiled medical records notes and promptly report and evaluate cases of loss or damage to the Head of HIMS.
- Gather and distribute reports on notification of infectious diseases to the MOH via email / fax or through the e-Notification system within the stipulated time (if applicable)
- Gather, collect, and dispatch the external form from the nearest JPN branch within the stipulated time.
- Indent and collect the external form from the nearest JPN branch to ensure availability.
- Liaise and communicate with medical practitioners to clarify incomplete, uncertain, or unclear documentation in patient medical records.
- Assist in assigning ICD and external cause code / procedure codes for all inpatient cases based on discharge diagnoses, in accordance with ICD regulations for statistical and reporting purposes.
- Liaise with Information Technology (IT) services for change request via the system to register new ICD code in the system.
Requirements:
Education:
- Sijil Pelajaran Malaysia (SPM) or other relevant qualifications.
Knowledge and Experiences:
- Preferably at least 1-5 years of experience from any established medical organization.
- Familiarity working in HIMS / medical records
- Familiarity with filing systems (terminal digit, straight numeric, etc.) preferred.
- Basic IT knowledge for Hospital Information System (HIS) use.
Skills & Competencies:
Special skills required
- Knowledgeable and committed to job responsibilities.
- Detail-oriented with a focus on accuracy.
Skills
Compliance