Assistant Medical Records Manager

1. Medical Records Operations

· Manage the daily operations, manpower and workflow of the Medical Records Unit.

· Ensure proper filing, retrieval, tracking, storage, archiving and retention of medical

records.

· Ensure timely availability of medical records to authorised users.

· Monitor missing, incomplete, duplicate or untraceable records and ensure appropriate

follow-up.

· Ensure proper retention and secure disposal of medical records in accordance with

applicable requirements.

2. Electronic Medical Records (EMR)

· Oversee and perform timely scanning and uploading of required documents into the

EMR.

· Ensure uploaded documents are complete, legible and correctly indexed to the correct

patient and encounter.

· Monitor missing, duplicate or incorrectly uploaded documents and ensure timely

rectification.

· Coordinate with IT and relevant departments on EMR issues, downtime processes, and

system improvements.

3. Medical Coding, Statistics & Statutory Reporting

· Oversee accurate and timely ICD-10 coding and reporting based on clinical

1. Medical Reports & Release of Information

·         Oversee processing of medical reports and requests for copies of medical records.

·         Ensure information is released only with appropriate patient consent or other authorised basis.

·         Monitor turnaround time for medical reports and record requests.

·         Ensure confidentiality and proper documentation of all information released.

5. Medical Records Quality & Governance

·         Serve as Secretary to the Medical Records Committee, including preparation of agenda, minutes, reports and follow-up of action items.

·         Coordinate and oversee closed medical record/chart reviews to monitor completeness, accuracy and compliance with documentation requirements.

·         Identify incomplete or deficient documentation and coordinate follow-up with the responsible doctors/departments.

·         Monitor outstanding and delinquent medical records and escalate prolonged non-compliance where required.

·         Develop, review and maintain the hospital’s Approved Abbreviations List in consultation with relevant clinical stakeholders.

·         Coordinate approval and periodic review of the abbreviation lists through the appropriate hospital governance process.

·         Analyse and present documentation deficiencies, trends and Medical Records indicators to the Medical Records Committee.

·         Monitor corrective and improvement actions arising from chart reviews, audits and committee decisions.

Confidentiality, Regulatory & Quality Compliance

·         Ensure confidentiality, privacy and security of patient information.

·         Ensure compliance with applicable Malaysian private healthcare requirements, PDPA, PHFS Act 1998 /CKAPS requirements, accreditation standards and hospital policies.

·         Maintain readiness for regulatory inspections, accreditation surveys and internal/external audits.

·         Coordinate corrective actions arising from audit or regulatory findings.

·         Escalate confidentiality breaches, loss of records or significant documentation issues to Management.

7. Leadership & Unit Management

·         Supervise, train and evaluate Medical Records Unit staff.

·         Plan manpower and allocate duties according to operational requirements.

·         Develop, implement and review Medical Records policies, SOPs and workflows.

·         Ensure staff competency in medical records management, EMR, coding and confidentiality requirements.

·         Monitor unit performance and implement continuous improvement initiatives.

PREFERENCE

• Knowledge of ICD-10 and ICD-11, medical records management, EMR/HIS, PDPA and Malaysian private healthcare regulatory requirements.
• Medical records and health information management
• ICD coding and healthcare statistics
• EMR/HIS management
• Clinical documentation review
• Confidentiality and data protection
• Regulatory and accreditation compliance