Assistant, Health Information Management System

Job Description: 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 . P rocess, and re ceived 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 record s 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.

Requirements

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.