Job Summary
The Medical Record Writer is responsible for preparing, typing, reviewing, and maintaining accurate patient medical documentation, including discharge summaries, operative notes, medical reports, referral letters, death summaries, and other clinical records. The role requires close coordination with consultants, nursing staff, and the Medical Records Department to ensure timely completion of patient documentation in compliance with hospital policies, NABH standards, and statutory requirements.
Key ResponsibilitiesMedical Documentation
- Prepare and type patient discharge summaries as dictated or approved by consultants.
- Draft medical reports, certificates, referral letters, and clinical documentation.
- Update patient case records accurately in the Hospital Information Management System (HIMS).
- Ensure all patient documents are completed before discharge.
- Verify completeness of patient records before filing.
Discharge Summary Management
- Coordinate with consultants for preparation of discharge summaries.
- Ensure discharge summaries are completed within the hospital's prescribed turnaround time.
- Verify diagnosis, investigations, procedures, medications, and follow-up instructions before finalization.
- Print, organize, and hand over completed discharge documents to the concerned department.
Medical Records Management
- Maintain complete inpatient and outpatient medical records.
- File, retrieve, and archive medical records as per hospital policy.
- Ensure proper indexing and record tracking.
- Maintain both electronic and physical documentation.
Documentation Quality
- Review records for completeness and accuracy.
- Follow up with doctors for pending signatures or incomplete documentation.
- Identify missing documents and coordinate with relevant departments for completion.
- Maintain documentation according to NABH and legal requirements.
Coordination
- Work closely with Consultants, Duty Medical Officers, Nursing Department, Billing, Insurance Desk, Quality Department, and MRD.
- Assist in medico-legal documentation when required.
- Coordinate for insurance documentation and claim-related reports.
Confidentiality
- Maintain strict confidentiality of patient information.
- Ensure patient records are released only with authorized approval.
- Follow hospital privacy and data protection policies.
Reporting
- Maintain daily discharge summary status reports.
- Track pending documentation.
- Prepare monthly documentation statistics.
- Support internal and external audits.
Qualification
- Bachelor's Degree in any discipline.
- Diploma or Certification in Medical Records, Medical Documentation, Healthcare Administration, or Hospital Administration is preferred.
- Knowledge of medical terminology is an added advantage.
Experience
- 1–3 years of experience in a hospital Medical Records Department.
- Experience in typing discharge summaries and clinical documentation is preferred.
- Freshers with excellent typing skills and medical terminology knowledge may also be considered.
Required Skills
- Excellent English typing skills.
- Strong knowledge of medical terminology.
- Good command of grammar and medical documentation.
- Knowledge of Microsoft Word, Excel, and Hospital Information Management System (HIMS).
- Ability to prepare accurate discharge summaries.
- Strong attention to detail.
- Good organizational and time management skills.
- Effective communication and coordination skills.
- Ability to maintain confidentiality.
Key Competencies
- Accuracy in documentation.
- Professionalism and integrity.
- Time management.
- Teamwork.
- Ability to work under pressure.
- Problem-solving skills.
- Commitment to quality and patient safety.
Key Performance Indicators (KPIs)
- 100% accurate discharge summaries.
- Timely completion of discharge documentation.
- Minimal documentation errors.
- Compliance with NABH documentation standards.
- Timely completion of pending medical records.
- Zero patient confidentiality breaches.
- Positive audit outcomes.
- Efficient coordination with consultants and clinical departments.
Pay: ₹10,028.83 - ₹32,528.23 per month
Benefits:
- Food provided
- Health insurance
- Leave encashment
- Life insurance
Work Location: In person
