Job responsibilities
JOB
TITLE: Medical
Note Summariser
LOCATION: Sackville
House, Cambourne
HOURS: As discussed
REPORTING
TO: Practice Manager
KEY
RELATIONSHIPS: All MMP Team members
ORGANISATIONAL
PURPOSE:
To
provide NHS General Practice services and act as a gateway to the wider NHS and
private health services.
JOB
SUMMARY:
The
practice strives to be a paperless environment, and the main responsibilities
of the post-holder will be to summarise and read code relevant information from
patients clinical records into the practice computer system, working strictly
in accordance with the practice notes summarising protocol.
Main
Duties/key tasks
Assess and sort patient records and letters in
preparation for summarising
Review medical records and produce accurate summary
of the patients medical history
Identify and code diagnoses, medical problems and
test results in line with protocol
Accurately Read Code and document information into
our data system
Allocate tasks to relevant clinicians for
appropriate actions.
File and retrieve paperwork, covering all coding
and summarising queries as necessary
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
- Demonstrate due regard for safeguarding and
promoting the welfare of children.
Equality and diversity:
The
post-holder will support the equality, diversity and rights of patients, carers
and colleagues, to include:
- Acting in a way
that recognizes the importance of peoples rights, interpreting them in a
way that is consistent with practice procedures and policies, and current
legislation
- Respecting the
privacy, dignity, needs and beliefs of patients, carers and colleagues
- Behaving in a
manner which is welcoming to and of the individual, is non-judgmental and
respects their circumstances, feelings priorities and rights.
Personal/Professional development:
The
post-holder will participate in any training programme implemented by the
practice as part of this employment, such training to include:
- Participation in
an annual individual performance review, including taking responsibility
for maintaining a record of own personal and/or professional development
- Taking
responsibility for own development, learning and performance and
demonstrating skills and activities to others who are undertaking similar
work
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
Communication:
The post-holder
should recognize the importance of effective communication within the team and
will strive to:
- Communicate
effectively with other team members
- Communicate
effectively with patients and carers
- Recognise
peoples needs for alternative methods of communication and respond
accordingly
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
NB: This job description is not meant to be
exhaustive and the post holder will be required to undertake any other duties
commensurate with the grading of the post.
Any changes to the job description will take place in consultation with
the post holder.
As Summariser you will have at least 6 months
proven experience in a similar role with previous experience of summarising
patient notes. You will possess the following key essential skills and
experience:
An understanding and background in medical terminology
Methodical, accurate with excellent attention to
detail
Excellent written and verbal communication skills
Ability to work under pressure and prioritise
workload
Excellent time management and organisational skills
Self-motivated with the ability to work under
pressure
Proficient user of Microsoft Office packages
The following are not essential but would be
advantageous: