Clinical Coder & Summariser

Job description

Job responsibilities

JOB TITLE: CLINICAL CODER & SUMMARISER

REPORTS TO: DOCUMENT MANAGMENT TEAM SUPERVISOR

HOURS: 35 HOURS PER WEEK OVER FIVE DAYS

Job summary:

The practice is already a paper-light environment, and the main responsibilities of the post-holder will be to summarise and read code relevant information from patient’s clinical records into the practice computer system, working strictly in accordance with the practice notes summarising protocol.

Job Purpose:

To ensure that all incoming and internal patient correspondence is stored on/in the patients’ medical record and relevant information is coded.

To be able to locate documents as needed by the clinical and non-clinical staff

To carry out administrative related tasks as delegated by the doctors and non- clinical staff

Key Working Relationships

The range of individuals and organisations the post holder has contact with, how regularly and for what purpose:

• Doctors, Nurses, HCA - Daily, where relevant to documents scanning
• Prescriptions Team - Daily, where relevant to documents scanning
• Administration Team - Daily, where relevant to documents scanning

Duties and Responsibilities

• Reviewing medical records and producing an accurate summary of the patient’s medical history.

· Read coding the information into the practice clinical system

• Auditing data collection standards in the practice
• Monitoring progress of notes summarising against practice targets
• Monitoring patient call and recall systems

· Filing and retrieving paperwork

• Take action as directed by other team members
• Follow practice protocols to ensure consistent and high quality care is provided to our patients
• Carry out administrative tasks relating to patient records, including filing, document management and ensuring patients can access reports, prescriptions and that they are easily accessible.

Scanning duties

• Sort and date stamp all incoming patient-related mail.
• Scan patient-related documents onto their medical record using read codes as agreed by the clinical team
• Add any additional information about the source of the document
• Workflow as needed forwarding the document to the doctor or nurse who initiated the referral or who is most appropriate to receive the information
• Ensure incoming letters are scanned onto the patient record within a 48/72-hour timescale
• Scan all internal paper documents on to the relevant patients’ record and then store the documents in line with surgery procedures.

Coding

• Identify relevant clinical information contained in patient correspondence
• Code or free text the clinical information on to the patient record
• Deal with queries relating to coding

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 holder’s 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 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 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
• 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

General Responsibilities for All Staff

The post-holder is expected to:

The post-holder must maintain the confidentiality of information about patients’ staff and practice business in accordance with the Data Protection Act 1998 and Caldicott principles.

Employees must be aware of the responsibilities placed upon them under the Health and Safety at Work Act (1974), to ensure that the agreed safety procedures are carried out to maintain a safe environment for employees and visitors.

All members of staff have a responsibility to report all clinical and non-clinical accidents, incidents or near-misses promptly and when requested to co-operate with any investigations undertaken.

All members of staff have a responsibility to demonstrate due regard for safeguarding and promoting the welfare of children.

The practice has adopted an equal opportunities policy and all employees must be aware of their obligations to abide by the spirit and nature of the policy to avoid direct and indirect discrimination.

Person Specification

Qualifications

Essential

• - Educated to GCSE level or equivalent

Desirable

• - National Clinical Coding qualification
• - Medical Terminology training

Experience

Essential

• - Experience of working in a GP surgery or an NHS office environment.
• - Experience of using NHS computer systems for records updates, ordering and other functions e.g. Read coding, data collection, hospital referrals

Desirable

• - Ability to work in a fast paced ever-changing environment
• - Experience of dealing with the public on the phone and face to face

Personal attributes

Essential

• - Friendly and approachable manner
• - Professional in approach
• - Calm and able to work under pressure
• - Able to work as part of a multi-skilled team with and/or without direct supervision
• - Flexible approach to the needs of the Practice.

Desirable

• - Enthusiasm for trying new applications and software

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

North Preston Medical Practice

Address

Ingol Health Centre

87 Village Green Lane

Ingol, Preston

Lancashire

PR2 7DS

Employer's website

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