Shipston Medical Centre

Document and Medical Records Assistant

This job is now closed

Job summary

Working 20-25 hours per week, this is an opportunity to work in an interesting and diverse role, within the medical records team. This would be suitable for someone with previous administrative experience and interested in a role within a healthcare setting. The role involves processing of documentation received from patients, out of hours services, as well as hospital settings which needs appropriate direction and recording in the patient’s medical records. In addition you will need to respond to patient’s requests for documentation and assistance.

The role also involves summarising and updating medical records, applying clinical coding to the patient’s record, (training will be provided), and therefore the candidate must have excellent attention to detail.

Main duties of the job

The successful candidate needs to be able to demonstrate being able to work with a variety of systems, and interacting with a variety of teams. Being thorough with attention to detail is key as you will be dealing with patient’s medical data. Patient data confidentiality needs to be adhered to.

Good communication skills are required – both in person, on the phone and written, to ensure clarity in information provision. Patience and the ability to remain calm in stressful situations is needed. There will be times where the role requires difficult communications to be made and the candidate needs to also be able to handle those difficult situations.

The successful candidate needs to evidence excellent organisational skills, and demonstrate ownership of their issues to conclusion.

The role involves a significant amount of computer work, across a variety of systems, and therefore the candidate must be able show their competence in main software packages and their aptitude to learn numerous other systems.

About us

Shipston Medical Centre provides primary health care services for the population of Shipston on Stour and the surrounding villages. We have around 11,700 patients and continue to grow as the population in the area grows. We are a patient focused and caring organisation which values education and development, and as such we have a long history of hosting learners and supporting colleagues in their professional development. Our focus on high quality evidence based care with compassion has enabled us to achieve and maintain our 'Outstanding' rating from the CQC.

We are currently in the process of developing new, larger premises in collaboration with South Warwickshire NHS Foundation Trust, which will centralise local services on the same site, alongside a community health and wellbeing hub.

The Medical Centre team are friendly, helpful and passionate about the care we provide. Looking after each other is as important as looking after our patients, and a key element of how we operate.

It is a legislative requirement that employees at the Medical Centre have a complete course of vaccination against COVID-19.

Date posted

12 January 2022

Pay scheme

Other

Salary

£16,604.52 to £18,499.60 a year The salary shown is pro-rata depending on experience

Contract

Permanent

Working pattern

Part-time

Reference number

A1017-22-0858

Job locations

Shipston Medical Centre

Badgers Crescent

Shipston on Stour

Warwickshire

CV36 4BQ

Job description

Job responsibilities

1) JOB IDENTIFICATION

Job Title: Medical Records and Document Management Assistant

Responsible to : Medical Records Manager/Practice Manager/Practice Partners

Department(s): Shipston Medical Centre

Last Update : Dec 2021

2. JOB PURPOSE

Provide and maintain high data quality via the notes summarising and correspondence management processes

Correspondence Management

Following protocols to filter incoming correspondence to support reduction in GP workload.

Following protocols appropriately direct documentation to the relevant clinician and/or team

To ensure that incoming patient information is logged and summarised effectively and in a timely fashion

and apply robust safety mechanisms for ensuring necessary actions are undertaken

Clinical Coding

Accurately code clinical information, within 3 days of receipt of document

Medical Records Management

Provide high quality, comprehensive notes summarising.

Medical Reports

Production of medical reports and related correspondence

System Support

Support users in use of various systems

3. DIMENSIONS

Responsible for supporting high quality data provision and maintenance of medical records of approximately 11,700 patients.

Participation in and attendance at meetings, such as monthly staff meetings, relevant training meetings etc.

Participation in annual appraisal and attending mandatory training, including CPR.

Attendance at necessary training events as required.

4. KEY RESULT AREAS

1. To ensure incoming correspondence is reviewed and actioned in line with protocols and actions for clinicians or other members of the practice team are logged and audited.

2. To accurately summarise patient notes, ensuring that clinical histories, diagnosis, investigations and other information is entered into the correct area of the patient record and are clinically coded accurately and prioritised according to practice protocol.

3. To ensure patient medical records received via GP to GP transfer are downloaded within three days of receipt, ensuring medications are inactivated and an alert to advise colleagues that these are not yet summarised is added to the notes.

4. To ensure all clinical notes received are logged on the computer record and tracked throughout each step of the summarising process or when ad-hoc requests received by clinicians.

5. To manage the requests and returns of patient notes to secure storage ensuring EMIS is up to date with progress and therefore their location is known accurately.

6. To ensure clinical information is summarised and maintained according to protocol and noted referrals, alerts, and warnings are actioned

7. Production of medical reports and related correspondence for third parties such as employers, solicitors, insurance companies, government agencies and regulatory bodies.

8. Quality audio typing of letters related to medical records enquiries.

9. Adherence to the practice’s policies, protocols and guidelines, including referral to GP and other agencies as practice policy dictates.

10. Actively participate in audit of work to ensure processes are robust, and highlight any recommendations for improvement, including documentation of proposals.

11. Support IT system management functions of the systems used within the practice.

12. To cover the work of colleagues during periods of leave, working reasonable overtime as required.

13. Strict adherence to patient confidentiality according to NHS guidelines and the Caldecott principles.

14. Adhere to the Practice’s Health and Safety Policy and maintain a safe working environment.

15. Adherence to all practice protocols and policies, including participation in the Medical Centre’s appraisal system.

16. Undertake any other tasks as may be required.

Personal Professional Development

1. Adherence to the practice’s appraisal policy and proactive participation in your development

2. Maintain professional development by attending appropriate courses and study days.

5a. EQUIPMENT AND MACHINERY

Computer and related software.

5b. SYSTEMS

Microsoft Applications

Clinical Information systems

Document management processes

Patient Communication systems

Notes summarising processes

Medical reporting processes

Participation in the practice appraisal process.

Participation in relevant working groups.

6. MOST CHALLENGING/DIFFICULT PARTS OF THE JOB

Need to be able to multi-task and respond to the multiple demands of the role

Answer phone and face to face enquiries from patients and third parties, ensuring appropriate professionalism and confidentiality is maintained.

Thoroughness and attention to detail is an absolute key part of the role.

Working to ensure processes are efficient and effective for all team members.

Support on-going changes within the team and wider practice

7. COMMUNICATIONS AND RELATIONSHIPS

The Medical Records and Document Management Assistant will regularly communicate with various people through face-to-face contact or via the telephone/e-mail.

Key relationships

Patients
Partners
Practice Manager
Document and Medical Records Manager
Document and Medical Records colleagues
Other members of the practice team
Third Party Companies

This Job Description will be subject to period review with the post holder and Manager