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Duties and Responsibilities
Assembles discharged inpatient records in accordance with established format.
Thins records as appropriate in accordance with MSD guidelines collaborating JCI Standards.
Performs quantitative analysis of discharged inpatient records and maintains computerized physician deficiency listings.
Abstracts demographic, statistical and medical information from each patient record.
Codes all established diagnoses and procedures performed by physicians as documented in each medical record for inpatient files, using the ICD10-CM classification system.
Performs final assembly/analysis and qualitative check for all completed records before returning to permanent files.
Prepares routine and ad-hoc statistical reports verifying accuracy of all information in accordance with the hospital policies and procedures.
Assists physicians, nurses and ancillary health personnel in completing and reviewing records.
Maintains confidentiality of all patient information in accordance with MSD collaborating JCI Standards and department/program policies and procedures.
Assists with the training of Saudi Nationals in accordance with the Saudization Objectives of the Program.
Participates in CQI & PS activities, including systems control, systems improvement and staff development.
Performs other duties/tasks within the realm of the individual’s knowledge, skills and abilities, as required.
Skills
A professional technician needs to understand and analyze patients’ diagnosis and procedures.
Accuracy and attention to detail are essential skills to have when processing and coding.
Technicians need to have a strong moral code. You need to be honest, ethical, and fair.
Technicians must be comfortable working with computers and technology.
Education
Health Informatics - Medical Records
Job Details
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