Kerja Sepenuh Masa, Assistant, Health Information Management System di KPJ Healthcare Berhad WP Kuala Lumpur - Maukerja

Education: 

• Sijil Pelajaran Malaysia (SPM) or other relevant qualifications.  

Knowledge and Experiences: 

• Preferably at least 1-5 years of experience from any established medical organization. 

• Familiarity working in HIMS / medical records  

• Familiarity with filing systems (terminal digit, straight numeric, etc.) preferred. 

• Basic IT knowledge for Hospital Information System (HIS) use. 

Skills & Competencies: 

Special skills required 

• Knowledgeable and committed to job responsibilities. 

• Detail-oriented with a focus on accuracy. 

• Retrieve and provide patient medical records notes upon requests via phone call or system for clinics, wards, Accident & Emergency (A&E), audits, or other authorized purposes. 

• Process, and received medical record notes from wards and clinics, ensuring all movements are accurately documented and tracked. 

• Receive, verify, and process inpatient medical record documents to ensure completeness and compliance with the discharge checklist. 

• Issue and release medical records notes only to authorized personnel and maintain and collate accurate tracking logs (manual or electronic) for all medical records notes movements. 

• File, arrange, scan, index and maintain returned medical record notes accurately. 

• Identify duplicate medical records and ensure the merging process is accurately executed and fully completed in accordance with hospital policies and data integrity standards.  

• Ensure and check that all medical records are stored securely and neatly under proper environmental conditions (clean, dry, and pest-free) and ensure maintenance of facilities in a proper condition. 

• Assist and liaise with staff in locating or retrieving missing or misfiled medical records notes and promptly report and evaluate cases of loss or damage to the Head of HIMS. 

• Gather and distribute reports on notification of infectious diseases to the MOH via email / fax or through the e-Notification system within the stipulated time (if applicable) 

• Gather, collect, and dispatch the external form from the nearest JPN branch within the stipulated time.  

• Indent and collect the external form from the nearest JPN branch to ensure availability. 

• Liaise and communicate with medical practitioners to clarify incomplete, uncertain, or unclear documentation in patient medical records. 

• Assist in assigning ICD and external cause code / procedure codes for all inpatient cases based on discharge diagnoses, in accordance with ICD regulations for statistical and reporting purposes. 

• Liaise with Information Technology (IT) services for change request via the system to register new ICD code in the system.