Junior Clerk - Medical Records

Maintains all Medical Record Documents in the right location on time, and attaches documents appropriately to the Electronic Medical Record (EMR) and patient binders. Tracks the location of records and documents that are delivered to clinical units. Delivers and collects records and documents to/from various locations throughout the facility; arranges deliveries to Satellite Clinics.

Minimum Requirements:

• High School Diploma

PROFESSIONAL EXPERIENCE:

• Minimum of two (2) years of experience in a healthcare setting in either Health Information Management (HIM) or Medical Records Department (MRD).
• Knowledge of medical terminology, appropriate level of healthcare and healthcare delivery systems preferred.
• Knowledge of terminal digit filing preferred.
• Skills in computer applications (e.g. Word, Excel, PowerPoint, Outlook, and email systems).
• Ability to speak and write in English fluently.

File Room Reception:

• Deals with all callers/visitors in a timely and professional manner.
• Monitors the File Room email and responds appropriately.
• Processes requests as per policy.
• Forwards release of information requests to the Release of Information (ROI) Unit.
• Keeps requesters informed by communicating availability/non-availability of the documents.
• Uses the tracking module to track the location of patient documents.
• Collects paper patient documents from clinical units and reviews them for:
• Appropriate patient identification
• Irregularities
• Non-approved documents
• Assigns to sorters, using terminal digit system.
• Scans and attaches documents to the appropriate Electronic Medical Records (EMR), using at least two patient identifiers.
• Ensures all scanned documents are attached to the correct encounter number (FIN), using the correct document type/title.
• Identifies document types that are not available in the health information system.
• Organizes by document type (external, informed consent, others) and processes as per policy.

Non-retrievable Documents:

• Maintains a log of missing documents for statistical and follow-up purposes.
• Follows up on priority documents in an ongoing and timely manner.

Preparation of Documents for Planned Procedures:

• Prepares the records as per the Operating Room schedule.
• Ensures necessary documents are available, follows up with the relevant clinic for non-available documents, and advises the inpatient units of the same.
• Delivers the documents to the appropriate units, by 19:00 hours, one day before the scheduled procedure.

Uploading Images CDs:

• Uploads external facility CDs containing images, as ordered, ensuring the images are correctly matched to the appropriate order.
• Coordinates with the ordering Clinic/IT Department.
• Maintains a log of all CDs received, uploaded, and collected.

Digitisation of Medical Records/ Disposal of Patient Information:

• Supports the digitisation of archived paper medical records by preparing the records, scanning, and confirming quality checks.
• Supports the disposal process for digitised medical records.
• Disposes of patient documents by a secure process (shredding).