Job Purpose
To accurately prepare, type, format, and maintain patient discharge summaries, ward summaries, medical reports, and other clinical documents based on the treating consultant's instructions while ensuring confidentiality, accuracy, and timely completion.
Key Responsibilities
- Type ward summaries, discharge summaries, operative notes, referral letters, medical certificates, and other clinical documents as dictated or provided by consultants.
- Ensure all patient details, diagnosis, treatment, procedures, investigations, and medications are entered accurately.
- Complete discharge summaries within the hospital's prescribed turnaround time.
- Verify patient demographics, UHID, admission/discharge dates, and consultant details before finalizing documents.
- Coordinate with doctors, nurses, and the Medical Records Department to obtain complete clinical information.
- Proofread documents for spelling, grammar, formatting, and medical terminology accuracy.
- Print, scan, upload, and file finalized summaries in the Hospital Information System (HIS) or Electronic Medical Record (EMR).
- Maintain confidentiality of all patient medical records in accordance with hospital policies and applicable legal requirements.
- Report incomplete or unclear documentation to the concerned consultant for clarification.
- Maintain proper documentation and records as per NABH standards.
- Assist in preparing medico-legal documents and insurance-related reports as assigned.
- Ensure proper storage and retrieval of electronic and physical records.
- Support audit activities related to medical documentation.
- Perform any other duties assigned by the reporting authority.
Qualifications
- Any Bachelor's Degree or Diploma.
- Certification in Medical Transcription or Medical Documentation is preferred.
Experience
- 0–2 years: Junior Ward Summary Typist
- 2–5 years: Ward Summary Typist in a hospital
- Experience working with HIS/EMR software is preferred.
Required Skills
- Excellent typing speed (minimum 35–45 WPM preferred)
- Good knowledge of medical terminology
- Proficiency in MS Word, Excel, and Hospital Information Systems (HIS)
- Strong attention to detail and accuracy
- Good written and verbal communication skills
- Ability to maintain confidentiality
- Time management and multitasking abilities
Benefits:
- Paid time off
- Provident Fund
Work Location: In person
