Medical Records Officer at Heartland Alliance

]Job Functions

The position supports, monitors, and ensures proper documentation, filing/storage, and retrieval of the client's care cards and personal medical records. These include ART, PrEP, and STI care cards. The job role also works closely within the SI unit in specific roles to support preemptive tracking of active ART clients and tracking inactive clients back to treatment.

Essential Duties and Responsibilities

• Take responsibility for maintaining the ART register on a day-to-day basis including allocation and control of Hospital Number/UID to all newly enrolled ART clients, transferred in, and transited clients.
• Ensure that the creation of Hospital Number/UID for all clients (ART, PrEP, PEP, STI) conforms with the HALG KPCARE1 data management standard operating procedure.
• Exercise control and day-to-day update of the PrEP register including allocation of Hospital number/UID.
• Take responsibility for the entry and day-to-day update of ART, PrEP, and Enrollment Register.
• Facilitate compliance with the use of client-level Change Management Procedures in respect of any correction/mutilation on any client’s folder (ART, PrEP, STI).
• Ensure that every change, update, and revision on any client’s folder (ART, PrEP, STI) goes through entry into the electronic medical records system.  
• Conduct data completeness checks on the client’s folder during submission by the clinic staff.
• Maintain an updated log/record of all care cards for all the LGAs supported by the OSS/Zone.
• Take responsibility for the systematic filing of clients’ folders using a serial-numeric approach and by LGAs.
• Create and maintain a tracking system to monitor the movement of care cards in and out of the Medical Records Office and within the different offices (M&E and Clinic) in the zone.
• Take responsibility to ensure that patients' Viral Load sample results are properly filed in the patients’ folders.
• Liaise with the DEC on a routine basis to ensure that folders of clients due for refill are sorted and sent to the nurse/clinic.
• Ensure that folders of IIT clients are sorted and made available to appropriate program/clinic staff for tracking.
• Identify and keep track of records for all dead, transferred out, and stopped treatment clients.
• Support data quality assessment using a standardized DQA checklist on the Documentation check list for ART, PrEP, and STI care cards.
• Ensure that individual patient ART care cards contain the following documents correctly and completely filled:
• A properly filled ART care card.
• Copy of the client’s referral form with Part A&B duly completed.
• A photocopy/clear duplicate copy of the HTS intake form.
• A properly filled Request and Result form.
• An adherence strategy work plan.
• Adult initial clinical evaluation form.
• White copy of Pharmacy order form properly signed by the pharmacy and the client.
• Laboratory Order and result form (when Lab services are provided.
• Viral load order and result form (when Lab services are provided).
• Client tracking and termination form (when clients have been tracked back to service/Stopped/LTFU).
• Transfer form (Exception only for client that are transferred from other HALG facilities)
• Maintain a systematic filing arrangement for client folders including LGAs and target groups separation.
• On a monthly basis review client’s folder for update on ART pick up [Pharmacy order form is a means of verification].
• Ensure Pharmacy Order Form is detached: Keep the white copy in client folder; blue copy in M&E arc folder and green copy in the Pharmacy unit.
• Ensure proper documentation on a PrEP care card which MUST contain the following;
  • Copy of the client’s referral form with Part A&B duly completed.
  • A photocopy/clear duplicate copy of the HTS intake form.
  • Request and result form clearly showing client is negative at initiation.
  • PrEP screening & eligibility form.
  • PrEP Pharmacy order form.
  • Ensure PrEP care cards are filed based on LGAs and target groups
  • On a monthly basis review client’s folder for updates on PrEP pick-up  [PrEP Pharmacy order form is a means of verification].
  • Perform other M & E-related duties as assigned by the SI lead.

Other Competencies:

• Time Management – Ability to prioritize tasks, manage time, and complete competing requests in a fast-paced, changing environment with minimal supervision.
• Quality   Management -  Looks for ways to improve and promote quality, accuracy, and thoroughness.
• Written Communication - Writes clearly and informatively.
• Adaptability - Adapts to changes in the work environment; Manages competing demands, able to creatively deal with frequent and unexpected demands.
• Cultural Sensitivity – Respect the cultural environment in which a person is working and does not act in a manner that is outwardly offensive to the local community.
• Non-discriminatory- Do not discriminate against persons based on sexual orientation or gender identity, age, preferred jobs, or behavioral habits.

Language Skills:

• Good oral and written English communication skills.
• Knowledge of Local Language will be an advantage.
• Must be able to speak fluently.

Computer Skills:

• Working knowledge of Microsoft Office, Internet Explorer, email .