Medical Records Assistant

Key Responsibilities:

Medical Records Management:

o Accurately file, organize, and maintain patient medical records (both physical and electronic) ensuring easy retrieval and accessibility.

o Ensure all patient records are complete, current, and in compliance with facility policies and regulatory requirements.

o Monitor and update patient information, admissions, discharges, and transfers promptly in the medical records system.

Data Entry & Documentation:

o Enter patient demographics, medical histories, and care details into electronic health record (EHR) systems.

o Verify accuracy and completeness of documentation submitted by physicians, nurses, and allied health staff.

o Support the preparation of medical summaries, discharge documents, and other required reports.

Confidentiality & Compliance:

o Safeguard patient confidentiality by following HIPAA-equivalent privacy laws and internal policies.

o Adhere to local Ministry of Health regulations and facility standards regarding medical documentation and record retention.

Coordination & Support:

o Assist healthcare professionals by locating and delivering patient records when needed for care delivery or legal purposes.

o Respond to requests for information from authorized personnel, patients, and external agencies.

o Support quality audits and accreditation processes by preparing relevant records and documentation.

Continuous Improvement:

o Participate in ongoing training and contribute to improving medical record processes.

o Identify and report any discrepancies, missing documentation, or process inefficiencies.

Qualifications & Experience:

Diploma or Bachelors degree in Health Information Management, Medical Records Administration, or a related field.

Minimum 1-2 years of experience in medical records, preferably in a hospital or long-term care facility.

Familiarity with Electronic Medical Record (EMR)/EHR systems and basic data entry software.

Understanding of medical terminology, documentation standards, and healthcare privacy regulations.

Skills & Competencies:

Strong organizational and time-management skills with attention to detail.

Ability to handle confidential information with integrity and discretion.

Effective communication and interpersonal skills.

Basic IT skills, including MS Office and healthcare information systems.

Ability to work collaboratively with clinical and administrative teams