Job responsibilities
Job Title: Scanner/Coder & Medical notes Summariser
Job Purpose:
To ensure that all incoming and internal patient
correspondence is stored in the patients medical record and relevant
information is coded.
Duties and
Responsibilities
- Take action as
directed by line manager
- Follow
practice protocols to ensure consistent and high quality care is provided
to our patients
Scanning duties
- Sort and date
stamp all incoming patient-related mail.
- Scan patient-related
documents onto their medical record using read codes as agreed by the
clinical team
- Add any additional
information about the source of the document
- Forward the
document to the most appropriate person
to receive the information
- Ensure
incoming letters are scanned onto the patient record within the practice policy
timescale
- Scan all
internal paper documents on to the relevant patients record and then
store the documents in line with surgery procedures.
Coding
- Identify
relevant clinical information contained in patient correspondence
- Code or free
text the clinical information on to the patient record
- Deal with
queries relating to coding
Medical notes Summariser duties
Main
duties/key tasks:
Culling and sorting patient records and letters in
preparation for summarising
Reviewing medical records and producing an
accurate summary of the patients medical history.
Read coding the information into the practice
clinical system
- Auditing
data collection standards in the practice
- Monitoring
progress of notes summarising against practice targets
Filing and retrieving paperwork
General
Responsibilities for All Staff
The post-holder is expected to:
- Adhere to
practice policies and procedures and relevant legislation including the requirements
of any professional bodies
- Attend mandatory
training as identified by the practice
- Highlight
potential development areas
All members of staff have a responsibility to
report all clinical and non-clinical accidents, incidents or near-misses
promptly and when requested to co-operate with any investigations undertaken.
All members of
staff have a responsibility to demonstrate due regard for
safeguarding and promoting the welfare of children.
The practice has adopted an equal opportunities
policy and all employees must be aware of their obligations to abide by the
spirit and nature of the policy to avoid direct and indirect discrimination.
Confidentiality:
- In
the course of seeking treatment, patients entrust us with, or allow us to
gather, sensitive information in relation to their health and other
matters. They do so in confidence
and have the right to expect that staff will respect their privacy and act
appropriately
- In
the performance of the duties outlined in this job description, the
post-holder may have access to confidential information relating to patients
and their carers, practice staff and other healthcare workers. They may also have access to information
relating to the practice as a business organisation. All such
information from any source is to be regarded as strictly confidential
- Information
relating to patients, carers, colleagues, other healthcare workers or the
business of the practice may only be divulged to authorised persons in
accordance with the practice policies and procedures relating to
confidentiality and the protection of personal and sensitive data
Health & safety:
The post-holder will assist in promoting and
maintaining their own and others health, safety and security as defined in the
practice Health & Safety Policy, the practice Health & Safety manual, and
the practice Infection Control policy and published procedures. This will
include:
- Using
personal security systems within the workplace according to practice
guidelines
- Identifying
the risks involved in work activities and undertaking such activities in a
way that manages those risks
- Making
effective use of training to update knowledge and skills
- Using
appropriate infection control procedures, maintaining work areas in a tidy
and safe way free from hazards
- Actively
reporting health and safety hazards and infection hazards immediately when
recognised
- Keeping
own work areas and general / patient areas generally clean, assisting in
the maintenance of general standards of cleanliness consistent with the
scope of the job holders role
- Undertaking
periodic infection control training (minimum annually)
- Reporting
potential risks identified
Quality:
The post-holder will strive to maintain quality within the practice,
and will:
- Alert
other team members to issues of quality and risk
- Assess
own performance and take accountability for own actions, either directly
or under supervision
- Contribute
to the effectiveness of the team by reflecting on own and team activities
and making suggestions on ways to improve and enhance the teams
performance
- Work
effectively with individuals in other agencies to meet patients needs
- Effectively
manage own time, workload and resources
- Demonstrate due regard for safeguarding and
promoting the welfare of children.
Contribution to the implementation of services:
The post-holder will:
- Apply
practice policies, standards and guidance
- Discuss
with other members of the team how the policies, standards and guidelines
will affect own work
- Participate
in audit where appropriate