Notes Summariser / Clinical Coder
Job summary
The post-holder is a Medical Summariser (Clinical Coder).
To be responsible for the read coding of relevant information into patients electronic healthcare records on the clinical system, adhering to the organisations coding policy. The role will mainly require clinical coding of new patient registration notes (that are not received electronically by GP-2-GP system).
The post-holder will be an integral part of the general practice team, and from time to time may be requirement to cover and assist with other clinical coding team duties as directed by the Clinical Coding Team lead or management team.
Main duties of the job
The following are the core responsibilities of the Medical Summariser / Clinical Coder in delivering health services. There may be, on occasion, a requirement to carry out other tasks. This will be dependent upon factors such as workload and staffing levels:
The following are the core responsibilities of the Medical Summariser / Clinical Coder in delivering health services. 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. Review records and accurately produce a summary of the patients medical history
b. Accurately SNOMED CT code data on the clinical IT system
c. Review progress of summarising, ensuring practice targets are achieved
d. Review all clinical letters, ensuring they are processed appropriately in line with extant protocols
e. File and store records in accordance with practice policies
f. Action all incoming correspondence, emails and mail in a timely manner if required
g. Scan patient related documentation and attach scanned documents to patients healthcare records if required
h. Correctly input data into patients healthcare records
i. Conduct system searches if requested
j. Support all clinical staff with general administrative tasks as requested particularly in relation to new patient notes and summaries
About us
We are a large GP practice based in mid-Cornwall with a registered patient list of 24,000 patients. We have a wide ranged multi-disciplinary team, and associated admin functions and operate from 5 locations including office space at Chy Trevail in Bodmin where this post will be based.
We are friendly , hard working and dedicated team who all provide excellent patient care.
Job description
Job responsibilities
In addition to the above the postholder will:
- Be an integral part of the general practice team
- Be aware of duties and responsibilities regarding current legislation and adhere to practice policies and procedures on Safeguarding Adults and Safeguarding Children
- Undertake all mandatory training and induction programmes
- Contribute to and embrace the spectrum of clinical governance
- Attend a formal appraisal with their manager at least every 12 months. Once a performance/training objective has been set, progress will be reviewed on a regular basis so that new objectives can be agreed
In addition to the primary responsibilities, the Medical Summariser / Clinical Coder has the following wider responsibilities:
- Participate in local initiatives to enhance service delivery and patient care
- Support and participate in shared learning
- Support Clinical Coding team, providing cover during staff absences
Person Specification
Qualifications
- GCSE grade A to C in English and Math
- Qualification in Medical Terminology and / or Clinical Coding
Experience
- Experience of working in a clinical coding team at Hospital or general practice level
- Experience of working in primary care
- Experience of working in a GP practice
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
Bosvena Health
Address
Bell Lane
Bodmin
Cornwall
PL31 2JJ
United Kingdom
Employer's website
https://www.bosvenahealth.co.uk/