Clinical Summariser/Coder

Eastwood Primary Care Centre

Information:

This job is now closed

Job summary

Eastwood Primary Care Centre is looking to recruit an enthusiastic and proficient Clinical Summariser to complement our friendly and dynamic team. If you are meticulous to details, hardworking and passionate about providing a high standard of care to our patients, we would like to hear from you.

The candidate must have experience in a healthcare setting and be familiar with clinical I.T. systems. Knowledge of medical terminology is essential.

Full-time or part-time hours are available. Informal visits and enquiries are welcome; telephone 01773 304703 

Main duties of the job

To process and record accurate data, to maintain quality information in patient records to support and help meet practice targets. The main responsibilities of the post-holder will be to summarise and read code relevant information from patients’ clinical records and clinical correspondence received into the practice computer system, working strictly in accordance with the practice notes summarising protocol.

About us

Eastwood Primary Care Centre is a large well-established practice of over 19000 patients, dedicated to delivering excellent healthcare to its patients.

Our multi-disciplinary team includes GPs, GP Registrars, ACPs, Clinical Pharmacists, Paramedic, First Contact Physio, Practice Nurses, HCAs, Phlebotomists & Nurse Associates. This is all supported by an extensive team of Receptionists, Secretaries and Administrators.

We constantly review our working processes and are open-minded about new challenges and ways of working. This is a really exciting time in primary care and an excellent opportunity for an appropriate candidate passionate about being part of and helping the practice to deliver an excellent service.

Date posted

11 January 2023

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Part-time

Reference number

A2321-23-7133

Job locations

Church Walk

Eastwood

Nottingham

NG16 3BH


Job description

Job responsibilities

Job Summary

To process and record accurate data, to maintain quality information in patient records to help meet practice targets. To provide practice support to the QOF framework across a number of domains. The practice is moving towards becoming a paper-light environment, and the main responsibilities of the post-holder will be to summarise and read code relevant information from patients’ clinical records and clinical correspondence received into the practice computer system, working strictly in accordance with the practice notes summarising protocol.

Job Responsibilities:

Summarising

  • Read code electronic and paper correspondence
          • Diagnoses
          • Procedures
          • Significant pathology
          • QOF data
  • Check the correspondence, whether sent direct to the summarising team or via the GP, and that it has been actioned appropriately ie: appointment/investigation booked.
  • Code any diagnosis, procedures etc. and record relevant patient information.

New Patient Summarising

  • Checking / adding all relevant medical history
          • Main diagnoses
          • Significant procedure/pathology
          • Vaccinations
          • Cytology
          • Allergies
          • Child protection/Safeguarding issues
          • Care pathways (GSF etc.)
  • Add to relevant Disease Register
  • Add any recalls

Child Protection

  • Read code and highlight records when information received
  • Task safeguarding administrator to add patient to surgery safeguarding list.

QOF Monitoring

  • Management of QOF disease registers and surgery recalls by producing monthly reports and adding/deleting patients accordingly

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 carer’s, 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, to 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 and free from hazards

• Reporting potential risks identified

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 people’s 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 team’s performance

• Work effectively with individuals in other agencies to meet patient’s 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

• Recognize people’s 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

Job description

Job responsibilities

Job Summary

To process and record accurate data, to maintain quality information in patient records to help meet practice targets. To provide practice support to the QOF framework across a number of domains. The practice is moving towards becoming a paper-light environment, and the main responsibilities of the post-holder will be to summarise and read code relevant information from patients’ clinical records and clinical correspondence received into the practice computer system, working strictly in accordance with the practice notes summarising protocol.

Job Responsibilities:

Summarising

  • Read code electronic and paper correspondence
          • Diagnoses
          • Procedures
          • Significant pathology
          • QOF data
  • Check the correspondence, whether sent direct to the summarising team or via the GP, and that it has been actioned appropriately ie: appointment/investigation booked.
  • Code any diagnosis, procedures etc. and record relevant patient information.

New Patient Summarising

  • Checking / adding all relevant medical history
          • Main diagnoses
          • Significant procedure/pathology
          • Vaccinations
          • Cytology
          • Allergies
          • Child protection/Safeguarding issues
          • Care pathways (GSF etc.)
  • Add to relevant Disease Register
  • Add any recalls

Child Protection

  • Read code and highlight records when information received
  • Task safeguarding administrator to add patient to surgery safeguarding list.

QOF Monitoring

  • Management of QOF disease registers and surgery recalls by producing monthly reports and adding/deleting patients accordingly

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 carer’s, 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, to 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 and free from hazards

• Reporting potential risks identified

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 people’s 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 team’s performance

• Work effectively with individuals in other agencies to meet patient’s 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

• Recognize people’s 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

Person Specification

Qualifications

Essential

  • GCSE English or above or equivalent

Desirable

  • Computer knowledge (formal qualification)

Personal Qualities

Essential

  • An understanding, acceptance and adherence to the need for strict confidentiality
  • Ability to use own judgement, resourcefulness and common sense
  • Ability to work without direct supervision and determine own workload priorities
  • Ability to work as part of an integrated multi-skilled team
  • Pleasant and articulate
  • Able to work under pressure
  • I.T. literate

Desirable

  • Good communication skills

Experience

Essential

  • Working in a healthcare setting
  • Working with clinical software
  • Knowledge of medical terminology

Desirable

  • Experience of SystmOne
  • Experience of working in NHS general practice
  • Experience of Microsoft Office software
  • Experience of dealing with the public/patients
Person Specification

Qualifications

Essential

  • GCSE English or above or equivalent

Desirable

  • Computer knowledge (formal qualification)

Personal Qualities

Essential

  • An understanding, acceptance and adherence to the need for strict confidentiality
  • Ability to use own judgement, resourcefulness and common sense
  • Ability to work without direct supervision and determine own workload priorities
  • Ability to work as part of an integrated multi-skilled team
  • Pleasant and articulate
  • Able to work under pressure
  • I.T. literate

Desirable

  • Good communication skills

Experience

Essential

  • Working in a healthcare setting
  • Working with clinical software
  • Knowledge of medical terminology

Desirable

  • Experience of SystmOne
  • Experience of working in NHS general practice
  • Experience of Microsoft Office software
  • Experience of dealing with the public/patients

Employer details

Employer name

Eastwood Primary Care Centre

Address

Church Walk

Eastwood

Nottingham

NG16 3BH


Employer's website

https://www.eastwoodprimarycarecentre.nhs.uk/ (Opens in a new tab)


Employer details

Employer name

Eastwood Primary Care Centre

Address

Church Walk

Eastwood

Nottingham

NG16 3BH


Employer's website

https://www.eastwoodprimarycarecentre.nhs.uk/ (Opens in a new tab)


For questions about the job, contact:

Finance & HR Manager

Sarah Petter

sarah.petter@nhs.net

01773304703

Date posted

11 January 2023

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Part-time

Reference number

A2321-23-7133

Job locations

Church Walk

Eastwood

Nottingham

NG16 3BH


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