Clinical Coder / Summariser

Job description

Job responsibilities

The following are the core responsibilities of the Clinical Coder and medical Summariser;

Summarising salient points (from patients previous practice summaries, checking through for medications, immunisations, chronic diseases, ongoing problems) and entering data on EMIS Web.

Summarising new patient records to a high standard and within agreed timescales; Restructuring existing computerised notes; Filing and retrieving paperwork; Produce a comprehensive electronic summary using Emis Web; Maintaining structure when recording new information; Assisting GPs and other health professionals with queries relating to medical records; scanning daily for incoming patient documentation in line with the practice procedure; To work as a member of the clinical coding/summarising team, with responsibility for own areas, inputting coded data into the clinical system.

Coding from information gathered from a number of sources including patient notes, discharge forms, both manual and electronic, and other clinical information captured on a variety of sources.

This will also involve running computer searches on to identify missing information; To work with other administrators and healthcare professionals to provide a high quality service to our patients; To ensure clinical coding is recorded in a timely and accurate manner in accordance with both national and local guidelines and standards; Snomed coding the information into the practice clinical system being aware of QOF requirements; To record sensitive information accurately e.g.HIV status, child protection register and safeguarding issues; Auditing data collection standards in the practice in clinical and administrative staff; Participate in audit where appropriate; To maintain clinical coding skills and participate in internal and external training programmes as required for both refresher and specialist clinical coding courses and work toward a high standard of coding; To extract, interpret and independently code clinical information from clinical letters and Discharge summaries from Hospitals and Clinics To participate in quality improvement initiatives, identifying areas where the processes used within the coding function can be improved and assist in implementing; To feedback coding information to senior management and to improve the quality and completeness of documents or clinical notes; To work in accordance with the service specification and clinical key performance indicators; To work In line with national, local and organisational priorities in order to affect good access for patients and to maximize activity and opportunity; Code all documents that are imported through the document manager on Emis; Review records to identify any apparent missing information I.e. childhood immunisations and liaise with PCSE or other relevant NHS department to complete the record as far as possible; File and store records as required; Photocopy documentation as required; Any other duties as may be determined from time to time commensurate with the range of activities described above

There may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels; Receiving and checking clinical notes for newly registered patients.

Person Specification

Qualifications

Essential

• Educated to GCSE level or equivalent

Desirable

• GCSE Mathematics and English (C or above)
• NVQ Level 2 in Health and Social Care
• Medical records summarisation qualification

Experience

Essential

• Experience of working in a healthcare setting
• Experience of clinical coding

Desirable

• Experience of working in a GP practice

Skills

Essential

• Excellent communication skills (written and oral)
• Strong IT skills
• Clear, polite telephone manner
• Competent in the use of Office and Outlook
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving and analytical skills
• Ability to follow policy and procedure
• Personal qualities
• Polite and confident
• Flexible and cooperative
• Motivated
• Forward thinker
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

The Maltings Surgery

Address

8-14 Victoria Street

St Albans

Hertfordshire

AL1 3JB

Employer's website

https://www.maltingssurgery.co.uk/ (Opens in a new tab)