South Sudan: Medical Record Consultant

As an integral component in the delivery of quality maternal and child health care in hospital is to establish an adequate standard for medical records. Medical records should be stored in a secure manner that allows access to authorized personnel only and safeguarded against loss or destruction and are maintained according to state requirements. However rapid assessment of in-patient medical records in six maternity hospitals in South Sudan shows noncompliance to standards and procedures. In some hospitals there are no records available for in patients whilst in other hospitals they are not organized and stored in manner that allows easy retrieval. If continuity of care for patients is to be assured, it is vital to keep good medical records, whether they are handwritten or electronic. Health professionals and others are able to use adequate medical records to reconstruct the essential parts of each patient contact, without the need to refer to memory.

Presently WHO supports the Ministry of Health in six tertiary hospitals providing comprehensive Emergency Obstetrics & Neonatal Care services with the overall goal of reducing maternal and neonatal mortalities through institutional and organizational capacity building. One of the essential components of the project is to support the establishment of standard in patient record system for the maternal & child health units in each of the six tertiary hospitals. The emphasis is on building a manual system but some discussions can be included on computerized applications which may be used as an adjunct when considering the introduction of some basic computerized systems later.

In consonance with this WHO is seeking for a qualified medical record consultant for the period of 4 months.

The aim of the consultancy is to help medical/health record workers in these hospitals to develop and manage the medical record/health information service in an effective and efficient manner.

1.Description of Tasks:

Under the overall guidance and direct supervision of the project manager and project officer the incumbent will undertake the following responsibilities:

Specific requirements

1. Carryout a rapid assessment of at least 3 hospitals medical records (primarily Maternal Child Health Unit) and determine the gaps, bottlenecks, challenges and address quality issues such as poor documentation and incomplete medical records

2. Work very closely with the state M&E focal point, Hospital Director General (DG) and the hospital record clerk to provide guidance and support in the development of the medical record systems

3. Work with the hospital management or State Ministry of Health to identify a person who can be trained to support systematic health records of patients in maternity

4. Provide capacity building for the hospital record clerk

5. Implement and maintain a master plan for the hospital record system

6. developing medical/health record policies, such as the retention of medical/health records, access to patient care information, privacy, confidentiality and the release of patient information;

7. Review of medical records to ensure that they are accurate, clinically pertinent, complete and readily available for continuing patient care, medico -legal requirements, and medical research;

8. Provide training for medical staffs on the importance of medical records and ensure staffs learn to complete all the medical records of patients under their care by recording a discharge diagnosis and writing a discharge summary (where required) for each discharged patient within a specified period of time;

9. Develop SOPs for management of medical records

10. Maintains medical records operations by following policies and procedures; reporting needed changes

11. Initiates medical record by searching master patient index; identifying existing patient records or need to assign a new number; interacting with registration areas and physicians' offices for information verification; processing or creating the record folder.

12. Visit 6 sites in the field for additional information for end of project report writing and establish data collection systems

13. Write a comprehensive report

Results/Expected Outputs:

1. One person identified and trained in each hospital to continue with the management of MNCH in-patient record

2. An initial assessment report completed and share with project team outlining problems and recommendations

3. A master plan for the MNCH record system is developed and implemented

4. Medical staff trained to support record management

5. A sustainable in-patient record system is developed

. Profile Requirements:

a) Qualification and experience:

Essential: The incumbent should be dynamic with good communication and writing skills. Preferably degree in Hospital administration, Health Informatics, statistics or Biostatics. However degree in related field such as health sciences, Public Health is also desirable.

Essential: 5 years of professional experience with an hospitals record department

Essential Technical Skills:

· Strong knowledge of Excel and preferably MS Access or other databases.

· Have experience in hospital management functions

· Data storage and file management expertise

· Assessment, Survey, and Monitoring and Evaluation expertise

· Time Management, Organization, Attention to Detail, Quality Focus, Professionalism, Productivity, Documentation Skills, Written Communication, Data Entry Management, Equipment Maintenance, Supply Management

· Medical Records Technician Skills and Qualifications:

· Capacity building skills

Desirable: Demonstrable experience of working in conflict country in the last 2 years

Languages:

• Excellent knowledge of English, with the ability to work in another UN language.
• Other Skills (e.g. IT): Excellent knowledge of Microsoft applications (e.g. Excel, Word, PowerPoint etc) with an emphasis on Excel and other epidemiological research application.

b)Skills:

Demonstrate knowledge in Communication, writing and data analysis skills.

c)Competencies and values:

Producing results (core)

Fostering integration and teamwork (core)

Building and promoting partnerships across the Organization and beyond (managerial)

Respecting and promoting individual and cultural differences (core)

1. The documents to be submitted with expressions of interest include :

2. o CV/ resume

3. o Example of previous work done on evaluation of projects

4. Interested candidate are encouraged to send letter of application and resume to

justinw@who.int with copy to pauls@who.int and gargarm@who.int