Medical Records Summariser / Clinical Coder

Job description

Job responsibilities

Main duties/key tasks:

· Culling and sorting patient records and letters in preparation for summarising

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

· Coding the information into the practice clinical system (Emis Web Clinical System)

· Auditing data collection standards in the practice

· Monitoring progress of notes summarising against practice targets

· Filing and retrieving paperwork

· Coding incoming clinical documents & electronic letters on to the clinical system

· Managing electronic GP2GP links and resolving degraded information

· Providing additional administrative support to workflow team (processing incoming documentation) or assisting with registration processes in times of need.

· Reviewing progress of summarising ensuring practice targets are achieved

· File and store medical records as required

· Photocopy documentation as required

· Action all incoming faxes, emails and mail in a timely manner

· Scanning of patient related documentation and attaching scanned documents to patient’s healthcare records

· Answer incoming phone calls, transferring calls or dealing with the callers request appropriately

· Carry out system searches as requested

· Help admin team with regards to sending medical records to the Health Authority

· Help admin team to do call-recall of the patients when required.

· Maintain a clean, tidy, effective working area at all times

· Support all clinical staff with general administrative tasks as requested

· Effectively manage Emis Workflow online documents- filing and coding appropriately

· Any other reasonable task

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

Flexibility:

This job description is not intended to be an exhaustive description of every duty performed by the post holder, but rather a guide to the type and nature of the duties. In Essex Lodge Surgery, flexibility in the duties undertaken and the hours worked are essential to achieve the objectives of a smooth running practice.

The post holder is required to carry out any duties that fall within the scope of this role, that may reasonably be requested by the Partners or the Practice Manager and that relate to the efficiency and smooth running of the Practice.

This job description is not exhaustive and may be adjusted periodically after review and consultation. You will also be expected to carry out any reasonable duties which may be requested from time-to-time.

Person Specification

Qualifications

• Good standard of general education
• GCSE English (C or above)

• NVQ Level -3
• Medical records summarisation qualification

Experience

• Experience of working within General Practice
• Experience of medical records summarising

• Experience of working in a GP Practice setting

Knowledge & Skills

• Knowledge of Emis Web Clinical System
• Excellent communication skills (Written and Oral)
• Competent in the use of Office and Outlook
• Understanding of clinical coding
• Effective time management
• Ability to work as a team member and autonomously

• Knowledge of Emis Web on Workflow Documentation Management
• Flexibility

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

Essex Lodge Surgery

Address

94 Greengate Street

London

E13 0AS

https://www.essexlodge.com/