Medical Record Specialist

Riyadh Hospital

Duties & Responsibilities:

• Reviews and audits medical records for completeness, accuracy and timeliness of care provided at Riyadh Hospital
• Maintain patient EMR including progress notes, evaluations, recommendations, charted weekly progress notes and quarterly summaries.
• Maintaining that patient charts and reports are accurately recording new information.
• Maintain patient records in compliance with MOH and security regulations.
• Ensure that the medical record contains sufficient information to identify the patient and his care provider, support the diagnosis, justify the treatment, and document the results of care provided.
• Ensure that only authorized staff are making entries in medical record.
• Ensure that the hospital uses nationally recognized standardized diagnosis and procedure codes reflected in EMR of the patient.
• Ensure that there is a process to ensure availability of the medical records in a timely manner.
• To ensure that there is a process to ensure paper or downtime medical records are consistently organized.
• To ensure that the hospital has a system for the retention of medical records in accordance with laws and regulations.
• To use the proper method for medical records destruction, when the retention period is complete
• Maintain proper storing conditions for RH medical records as needed by MOH ,CBHI, JCI and other accreditations
• To develop a system to identify the location of any record not in the medical records department and its date and time of movement as well as subsequent movements, when applicable.
• Ensures that the hospital uses standardized forms in medical records, generated based on hospital needs and the needs of healthcare professionals.
• Participate effectively in Medical record review committee.
• Ensure that all entries in the medical records must be legible, indelibly verified, dated, and authenticated as needed.
• Ensure that there is a discharge summary for all discharged patients and that all EMR contains full medical report of the case.
• Reviews all submitted or attached forms to EMR.
• Facilitate modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and health records coding staff to improve quality, accuracy, and completeness of clinical documentation in real-time
• Improvise medical policies and procedures in compliance with the accreditation standards.
• Comply with CBAHI standards, CCHI standards, ICD-10, ICD-11, ACHI, Clinical Documentation Improvement and Integrity national and international guidelines.
• Compile statistical information and registers pertaining to the medical records department.
• Monitor and document the requisition of supplies for the department.
• Processes legal medical documents, insurance data and corresponding requests.

Qualification & Experience Requirements:

• Bachelor s degree in healthcare information management or health information management Certification with a clinical background (AHIMA or equivalent).
• Minimum 2 years of experience is preferred.

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