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