Clerk IV, Record Completion

Work Area: 
Base Site: 
Squamish General Hospital
Job Category: 
Health Information Management
As per the current Public Health Orders (Long Term Care/Seniors Assisted Living Provincial Health Order and the Health Sector Order), as of October 26, 2021, all employees working for Providence Health Care must be fully vaccinated against COVID-19. Proof of vaccination status will be required.
Health Information Management (HIM) provides services for Fraser Health (FH), Providence Health Care (PHC), the Provincial Health Services Authority (PHSA) and Vancouver Coastal Health (VCH). HIM is a leader in the collection, storage, and use of patient information within British Columbia. Providence Health Care is the lead organization for HIM, and employs over 1,350 HIM staff across Metro Vancouver, the Fraser Valley, the Sea-to-Sky Corridor, the Sunshine Coast and the Regional Cancer Centres (Victoria, Kelowna, Prince George, Abbotsford, Surrey, Vancouver).


Under the supervision of the Manager or Coordinator, performs quantitative analysis on patient records by checking for completeness of the record. Maintains the record completion system in accordance with departmental policies, procedures and standards. Administers the physician suspension process regarding non-compliance regarding record completion.


Ability to communicate effectively both verbally and in writing.
Ability to deal with others effectively.
Knowledge of medical terminology.
Physical ability to carry out the duties of the position.
Ability to operate related equipment.
Ability to keyboard at 45 wpm.


Grade 12, plus two years recent, related experience or an equivalent combination of education, training, and experience.


Performs quantitative analysis on records by checking for completeness of the record (e.g., discharge summary, operation reports) and forwarding incomplete records to physician for completion in accordance with quantitative analysis procedures and within the organization’s guidelines and standards.

Enters deficiencies into computerized record completion module and files onto patient records.

Maintains record completion systems by performing duties such as printing and distributing weekly physician notices of incomplete records and printing and distribution of reports to Medical Administration, VP Medicine and Department Heads.

Administers the physician temporary suspension process regarding non-compliance around record completion in accordance with departmental procedures; generates pending suspension notices to physicians; notifies appropriate departments such as Registration of temporary suspension due to non-compliance.

Maintains records control by ensuring that all records are signed out in the tracking program according to established policy and procedures

Responds to physician queries regarding incomplete records.

Follows up with departments such as Registration regarding problems with documentation such as questionable encounters, duplicate registrations and merges. Takes the appropriate steps to correct or resolve problems as required. Initiates edits and merges duplicate numbers as required.

Participates in the quality assurance monitoring and audit functions by assisting the Area Coordinator by performing duties such as conducting actual reviews of incomplete records, counting records and maintaining workload statistics.

Follows up on missing records by performing detailed searches within the department and on the nursing units.