Job responsibilities
The Limehouse Practice
Job Description
Job Title: Clinical Coder
Reports to: GP partner/Practice Manager
Hours 37.5 hours
9:00 17:00 Mon Fri
Job summary:
The purpose of the role is to:
Review all incoming correspondence filing the document and entering pertinent information into the patients electronic medical record in accordance with the Coding Protocol with attention to QOF.
Highlight clinician action and workflow to appropriate clinician or team as per Workflow Protocol.
To be responsible for the read coding of relevant information into patients electronic healthcare records on EMIS clinical system, adhering to the correspondence management policy.
Organise the medical record of patient whom you are coding, to link problem titles.
Checking incoming medical records and summarising onto clinical system.
Recognise own knowledge limits and seek advice from clinical or administrative colleagues as appropriate.
To carry out administrative related tasks as delegated by Clinical Lead and Practice Manager.
Duties and 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. Accurately clinically coding data on EMIS into the patient record
b. Identifying relevant clinical information documented in patient correspondence, coding appropriately and completing any detailed action
c. Inputting and extracting data as required to support practice reports
d. Filing and storing records as required
e. Photocopying documentation as required
f. Actioning all incoming correspondence, emails and mail in a timely manner
g. Scanning of patient related documentation and attaching scanned documents to patients healthcare records
h. Inputting data into patients healthcare records as necessary
i. Answering incoming telephone calls, transferring calls or dealing with the callers request appropriately
j. Carrying out system searches as requested
k. Maintaining a clean, tidy, effective working area at all times
l. Check incoming medical summaries and record into the clinical system.
In addition to the primary responsibilities, the Clinical Coder may be requested to:
a. Review and update the practice coding policy as required (in conjunction with the Deputy Practice manager.
b. Partake in audit as directed by the audit lead
c. Support reception staff, providing cover during staff absences
d. Book appointments
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 recognises 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 that 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, with 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 recognise 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