Job responsibilities
Job Responsibilities
The post holder to ensure the following:
General
To summarise and code patient records into the Practices computer system to a high standard
Read all incoming correspondence to the practice, accurately coding the relevant diagnosis/procedure/information is in the patients records, deciding whether to send on to a GP, ensuring follow up actions/tests are brought to the attention of the relevant staff
Analysing patient records and extracting and accurately recording all relevant clinical information toproduce an accurate summary of the patients medical history
Sort and date stamp all incoming patient-related mail
Scan patient-related documents onto their medical records using codes as agreed by clinical team
Ensure incoming letters are scanned onto the patient record within a 48/72 hour timescale
To move relevant lab reports ,prescriptions, documents to the appropriate clinical staff to ensure that no results are missed
Checking and integrating medical records received electronically
Examining records and documentation for missing information
Assigning industry-recognised codes
Ensuring that all QOF related data is captured
Maintain and improve a knowledge of anatomy, physiology and medical terminology
Use medical knowledge to correct mistakes found in existing patient records.
Collaborating with clinical colleagues and other healthcare professionals to ensure information accuracy
Ensuring that the practice complies with clinical coding guidelines
Ensuring that all clinical codes are current
Following practice protocols to ensure consistent and high-quality care is provided to our patients.
Responsible for new patient registrations
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Team Working
Understand own role and scope and identify how this may develop over time.
Work as an effective and responsible team member, supporting others.
Prioritise own workload and ensure effective time-management strategies are embedded.
Work effectively with others to clearly defined values, direction and policies.
Discuss, highlight, and work with the team to create opportunities to improve patient care.
Confidentiality
In the undertaking of the duties outlined above the post-holder will have access to confidential and sensitive information relating to patients, carers and practicestaff.This must be kept strictly confidential at all times.
Patients seeking information from the practice do so in confidence and as such have the right to expect that staff will respect their privacy and act appropriately
Policies and procedures relating to the protection of personal and sensitive data must be adhered to at all times and only divulged to authorised persons.
Health & safety & Risk Management
The post holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice health and safety policy, to include:
Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks
Reporting potential risks identified to the partners and actions required to remedy if needed.
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 which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.
Ensure that all statutory requirements regarding equality and diversity are met
Personal 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
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 supervisionand effectively manage own time ,workload and resources
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
Communication:
The post-holder should recognise the importance of effective communication within the team and the wider Health economy, and will strive to:
Communicate effectively with the practice partnersand all practice team members
Communicate effectively with patients and carersand recognise peoples needs for alternative methods of communication and respond accordingly
Communicate effectively with all associated staff in the wider health economy
Other Duties
The Clinical Coder may, from time to time, be asked to undertake other reasonable duties, with appropriate training if required. It is important that all members of staff are prepared to undertake additional or relinquish current duties to maintain service delivery to patients. It is expected that requests from the Partners will not be unreasonably refused.