| Detail | For this role |
|---|---|
| Department | Hospital Administration |
| Level | Mid level |
| Reports to | Hospital Administrator or Medical Superintendent |
| Direct reports | Medical Records Technician, Medical Coder |
| Experience | 5 to 8 years in medical records, with some team handling |
Medical Records Officer job description template
Copy this job description, replace the text in square brackets and post it on your careers page or a job portal.
Job title: Medical Records Officer
Department: Hospital Administration
Reports to: Hospital Administrator or Medical Superintendent
Location: [City], [office, branch or site]
About the role
A Medical Records Officer runs the medical records department that stores and protects every patient's clinical file. They ensure records are complete, coded, stored and retrievable, oversee ICD coding and record completion by doctors, and handle medico-legal and insurance requests for records. The role keeps the department compliant with retention rules and NABH, and protects patient confidentiality. In an Indian hospital the medical records officer manages record clerks and coders, tracks incomplete files, and is the custodian who releases records only to authorised requests under a clear process.
Key responsibilities
- Ensure every inpatient and OPD record is assembled, complete and filed after discharge within the agreed time.
- Oversee ICD coding of diagnoses and procedures and check coding accuracy for reporting and claims.
- Track incomplete records and follow up with doctors so deficiencies are closed within the deadline.
- Store records safely, whether physical or scanned, and keep them retrievable within the target time.
- Handle medico-legal, insurance and patient requests for records under a clear authorisation process.
- Maintain confidentiality and release records only to authorised persons per policy and law.
- Apply the record retention and destruction schedule as per statutory and hospital rules.
- Keep the department ready for NABH by maintaining record completion and coding indicators.
- Prepare statistics such as disease and procedure counts for management and statutory reporting.
- Supervise record clerks and coders, plan the roster, and train them on process and confidentiality.
Requirements
- Bachelor's or diploma in Medical Records Science or Health Information Management
- Knowledge of ICD coding and record retention rules
- A hospital administration qualification is an advantage
- 5 to 8 years in medical records, with some team handling
KRAs and KPIs for a Medical Records Officer
Key result areas for the appraisal form, each with a KPI you can measure every month or quarter.
| Key result area | How to measure it |
|---|---|
| Record completion | Discharged records assembled and completed within the agreed time, backlog kept low |
| Coding accuracy | ICD coding accuracy at or above the agreed level on audit |
| Retrieval time | Requested records retrieved within the target time |
| Deficiency closure | Incomplete record deficiencies closed by doctors within the deadline |
| Confidentiality | Zero unauthorised release of records during the year |
| Retention compliance | Retention and destruction schedule followed with records for audit |
Skills and tools
Tools used day to day: Medical records or HIM software, ICD coding references, Hospital Information System (HIS), MS Excel, Document scanning system.
Reporting line and career path
Next roles: Medical Records Manager, Health Information Manager, Hospital Administrator
Interview questions for a Medical Records Officer
- How do you cut the backlog of incomplete records without annoying busy doctors?
- A lawyer requests a patient's records. Walk me through your release process.
- How do you keep coding accurate enough for both statistics and insurance claims?
- What is your record retention schedule, and how do you handle destruction?
- How would you keep patient records confidential in a shared department?
- What medical records indicators would you show at an NABH assessment?
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What does a medical records officer do?
A medical records officer runs the department that stores and protects patient clinical files. They ensure records are complete, coded, stored and retrievable, oversee ICD coding, track incomplete files, and handle medico-legal and insurance requests. They maintain confidentiality, apply retention rules, prepare statistics, and keep the department ready for NABH while supervising record clerks and coders.
What qualifications does a medical records officer need?
A bachelor's or diploma in medical records science or health information management is the usual qualification, with knowledge of ICD coding and record retention rules. A hospital administration qualification is an advantage. Employers look for several years in medical records, attention to detail, and a strong sense of patient confidentiality and process discipline.
What is the difference between a medical records officer and a medical coder?
A medical coder assigns ICD and procedure codes to diagnoses and treatments for records and claims. A medical records officer runs the whole department: completion, storage, retrieval, medico-legal requests, retention and confidentiality, and supervises coders and clerks. The coder is a specialist within the department the officer manages.