Occupations and Terms of Reference › Medical records manager
Universal terms of reference · POS-148 · version 1.0 · status: draft · next review 2027-10-27
Medical records manager
To manage medical records, so that every patient's record is complete, accurate, secure and available when clinicians need it.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You manage medical records. You lead the records team, set standards for documentation and storage, manage access and retention, and make sure records are available and audited.
Reports to: Patient services manager.
Leads or supervises: Medical records clerks and medical coders.
What you do on a typical day
- Review record availability and missing records each week.
- Set documentation and retention standards.
- Manage access requests and audits.
- Lead the records team.
- Report records quality to the quality committee.
Working conditions and demands
- Confidential and legal data.
- Time pressure on record retrieval.
- Works with clinicians and coders.
What good looks like
- Records are available when needed.
- Access is controlled and audited.
- Records meet the documentation standard.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Patients are treated with dignity, respect and privacy at every step.
- Accurate information is given to patients and families, in a language they understand.
- Confidential information is protected and used only for care, legal and agreed purposes.
- Safety comes first: errors are reported, reviewed and learned from without blame.
- Medicines, records and appointments are handled to the standard, every time.
- Anyone can raise a concern without fear of reprisal.
- Waiting and flow are managed fairly, with patients kept informed.
- Work is done to written procedures, and deviations are reported.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-148 |
| ISCO-08 | 1342 (skill level 4) |
| ESCO | to map |
| Department | Patient administration |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-144. Supervises: POS-149, POS-150.
| Works with | Nature of the relationship |
|---|---|
| Patient services manager | Records and registration. |
| Clinical audit officer | Records audit. |
| Data protection officer | Confidentiality and access. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Records standards | Sets and maintains records standards and retention. | Standards reviewed yearly | Annually | C-01 | T-04 | POL-DATA | 2 |
| Access | Manages access and checks it against need. | Access audit passed | Quarterly | C-02 | T-04 | POL-DATA | 2 |
| Availability | Keeps records available when clinicians need them. | Missing records under agreed limit | Weekly | C-01 | T-08 | – | 2 |
| Team | Leads the records team. | Team appraisals completed on time | Annually | C-03 | T-08 | POL-EQUAL | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Records retrieval and filing procedures | Data breaches (data protection officer and CEO) |
| Access decisions within policy | Access requests from outside the organisation (data protection officer) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Health information management qualification | Yes | Lifetime |
| Q-02 | Degree in health information or a related field | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Medical records or health information management | 5 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | C-01 · C-02 |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | – |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | – |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | – |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | C-03 |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Records standards and retention | Follows records rules | Manages records in a service | Designs records standards | Records audit | Every 12 months | T-04 |
| C-02 | Access and confidentiality | Protects records | Manages access | Designs access controls | Access audit | Every 12 months | T-04 |
| C-03 | Leading records teams | Works in a team | Leads a records team | Develops records leadership | 360 feedback | Every 24 months | T-08 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Records available on request | 95% or more | records log | Weekly |
| PI-02 | Access audit passed | 100% | access audit | Quarterly |
| PI-03 | Records meeting standard | set by facility | records audit | Quarterly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Medical records manager | 5 years (recommended) | Q-01 | C-01 expert, C-02 practitioner | T-04 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |