Job responsibilities
Coltishall Medical
Practice
Job Title: Medical Records
Summariser / Clinical Coder
Line Manager: IT &
Data Quality Manager
Accountable to: Practice
Manager
Hours per week: Minimum of 25 hours
Job Summary
To compile a comprehensive and chronological
medical summary from new patient records.
To identify and enter key clinical information into
the Emis Web clinical system in accordance with the Practice note summarising
and clinical coding protocol.
To ensure
that all incoming correspondence is coded appropriately and sent by workflow system (DOCMAN) where
appropriate for clinicians to action any other directions in a timely way.
The post-holder will also support the
multi-disciplinary team, providing administrative support as required, in
line with the needs of the practice.
Generic Responsibilities
All
staff at Coltishall Medical Practice have a duty to conform to the following:
Equality, Diversity & Inclusion
A good attitude and positive action towards
ED&I creates and environment where all individuals are able to achieve
their full potential. Creating such an environment is important for three
reasons: it improves operational effectiveness, it is morally the right thing
to do, and it is required by law.
Patients and their families have the right to be
treated fairly and be routinely involved in decisions about their treatment
and care. They can expect to be treated with dignity and respect and will not
be discriminated against on any grounds including age, disability, gender
reassignment, marriage and civil partnership, pregnancy and maternity, race,
religion or belief, sex or sexual orientation. Patients have a responsibility
to treat other patients and our staff with dignity and respect.
Staff have the right to be treated fairly in
recruitment and career progression. Staff can expect to work in an
environment where diversity is valued and equality of opportunity is
promoted. Staff will not be discriminated against on any grounds including
age, disability, gender reassignment, marriage and civil partnership,
pregnancy and maternity, race, religion or belief, sex or sexual orientation.
Staff have a responsibility to ensure that you treat our patients and their
colleagues with dignity and respect.
Safety, Health,
Environment and Fire (SHEF)
This practice is committed to supporting and
promoting opportunities to for staff to maintain their health, well-being and
safety. You have a duty to take reasonable care of health and safety at work
for you, your team and others, and to cooperate with employers to ensure
compliance with health and safety requirements. All personnel are to comply
with the Health and Safety at Work Act 1974, Environmental Protection Act
1990, Environment Act 1995, Fire Precautions (workplace) Regulations 1999 and
other statutory legislation.
Confidentiality
This
practice is committed to maintaining an outstanding confidential service. Patients
entrust and permit us to collect and retain sensitive information relating to
their health and other matters, pertaining to their care. They do so in
confidence and have a right to expect all staff will respect their privacy
and maintain confidentiality at all times. It is essential that if, the legal
requirements are to be met and the trust of our patients is to be retained
that all staff protect patient information and provide a confidential service.
Quality & Continuous Improvement (CI)
To
preserve and improve the quality of our output, all personnel are required to
think not only of what they do, but how they achieve it. By continually
re-examining our processes, we will be able to develop and improve the
overall effectiveness of the way we work. The responsibility for this rests
with everyone working within the practice to look for opportunities to
improve quality and share good practice.
This
practice continually strives to improve work processes which deliver health
care with improved results across all areas of our service provision. We
promote a culture of continuous improvement, where everyone counts and staff
are permitted to make suggestions and contributions to improve our service
delivery and enhance patient care.
Induction Training
On arrival at the
practice all personnel are to complete a practice induction programme; this
is managed by the Practice Manager.
Learning and Development
The
effective use of training and development is fundamental in ensuring that all
staff are equipped with the appropriate skills, knowledge, attitude and competences
to perform their role. All staff will be required to partake and complete
mandatory training as directed by the training coordinator, as well as
participating in the practice training programme. Staff will also be permitted (subject to
approval) to undertake external training courses which will enhance their
knowledge and skills, progress their career and ultimately, enable them to
improve processes and service delivery.
Collaborative Working
All
staff are to recognise the significance of collaborative working. Teamwork is
essential in multidisciplinary environments. Effective communication is
essential and all staff must ensure they communicate in a manner which
enables the sharing of information in an appropriate manner.
Service Delivery
Staff
at Coltishall Medical Practice must adhere to the information contained with
practice policies and regional directives, ensuring protocols are adhered to
at all times. Staff will be given detailed information during the induction
process regarding policy and procedure.
Security
The
security of the practice is the responsibility of all personnel. Staff must
ensure they remain vigilant at all times and report any suspicious activity
immediately to their line manager. Under no circumstances are staff to share
the codes for the door locks to anyone and are to ensure that restricted
areas remain effectively secured.
Professional Conduct
At
Coltishall Medical Practice staff are required to dress appropriately for
their role. Patient facing administrative staff will be provided with a
uniform whilst clinical staff must dress in accordance with their role.
Primary Responsibilities
The
following are the core responsibilities of the clinical coder. There may be
on occasion, a requirement to carry out other tasks; this will be dependent
upon factors such as workload and staffing levels:
a.
Summarise new patient medical records, ensuring full record
received both electronically and paper records. De-duplicate paper records.
b.
Record information from New patient questionnaire
c.
Report any existing safeguarding coding, check for
household connections, advise any other relative information to the
Safeguarding Lead.
d.
Review records to identify any apparent missing
information i.e. childhood immunisations and liaise with PCSE, Child Health
or other relevant NHS department to complete the record as far as possible.
e.
Review records received by GP2GP, entering missing data
and update warning information where this system has failed, obtaining
summary information from patients previous practice as required.
f.
Enter test results and consultation data into patient
records ensuring accuracy and compliance with the Practice clinical code
policy.
g. Identifying relevant clinical information documented in
patient correspondence, coding appropriately and forwarding to clinicians to complete
any detailed actions within appropriate timescales.
h.
Raise any concerns or issues proactively and in a
timely manner to your Line Manager or the Practice Manager in their absence.
i.
File and store records as required
j.
Maintain a clean, tidy, effective working area at all
times
k.
Support all clinical staff with general administrative
tasks as requested
Secondary Responsibilities
In
addition to the primary responsibilities, the Medical Records
Summariser / Clinical Coder may be requested
to:
a.
Review and update the practice coding policy as
required (in conjunction with the IT & Data Quality Manager)
b.
Partake in audit as directed by the audit lead
c.
Any other duties commensurate with skills and responsibilities.
This
document may be amended following consultation with the post holder, to
facilitate the development of the role, the practice and the individual. All
personnel should be prepared to accept additional, or surrender existing duties,
to enable the efficient running of the practice.