Medical Documents

 

Head of Medical Documents

Ms. Abbasi

 

Medical Document includes four parts:

Statistics, Coding, Archiving, Admission

 

Responsibilities of Coder:

 

  • Observing hospital rules and regulations
  • Coding initial diagnosis based on the ICD10 book
  • Coding final diagnosis based on the ICD10 book
  • Coding the external cause based on the ICD10 book
  • Coding the underlying cause of death based on the ICD10 book
  • Coding of surgical procedures and operations based on the ICD9CM book
  • Responding to letters from legal and competent authorities in coordination with the expert of medical records
  • Carrying out all assigned tasks according to the superior order

 

 

Responsibilities of expert of Statistics:

 

  • Observing hospital rules and regulations
  • Following up and preparing the required forms of the office to collect statistical information
  • Following up and receiving completed statistical forms from all wards of the hospital
  • Calculating and presenting statistical indicators
  • Submitting statistics to the University Statistics Office monthly
  • Responding to statistical letters sent to the statistics office according to the superior order
  • Providing monthly and annual statistics of all hospital activities
  • Maintaining records of forms and reports in accordance with relevant regulations
  • Carrying out all assigned tasks according to the superior order

 

 

Responsibilities of Archiver:

 

  • Observing hospital rules and regulations
  • Receiving a complete medical file and registering in the file entry office
  • Arranging papers and deleting extra file papers
  • Striving to observe the principle of confidentiality of information by observing the principles of transferring medical records
  • Retrieving and delivering medical records from the archive to the applicant based on the rules and instructions for delivery of medical records
  • Following up to return the files that have been delivered to the departments.
  • Counting the files before sending or delivering the file to the applicant and checking it at the time of receiving the file
  • Preparing reports of activities and submitting them to the relevant supervisor
  • Responding to letters from legal and competent authorities in coordination with the expert of medical records
  • Carrying out all assigned tasks according to the superior order
  • Following up incomplete files to be completed by physicians
  • Recording the code assigned to the file in the HIS program
  • Archiving medical records properly according to archiving instructions