Job summary
The advertised role is for a medical notes summariser and clinical coder to work as part of our experienced administrative team.
This is flexible work that can be fitted around other commitments.
Main duties of the job
The practice is moving towards becoming 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.
About us
We are a dispensing practice in rural Northumberland. Currently we have 3 GP partners. We employ around 18 staff, including a Nurse Practitioner, 2 Health Care Assistants, dispensers, admin staff and delivery drivers. We host attached staff such as podiatrist, anticoagulant nurses, as well as Primary Care Network staff.
We are strongly committed to providing high quality person centred care and to the personal and professional development of all members of the practice team
Job description
Job responsibilities
Please see attached document for full job description, but main duties listed here:
Clinical coding
1. accurately code clinical information form patient records, including diagnoses, procedures and treatments.
2. Ensure coding is completed promptly to facilitate patient care and practice reporting requirements.
3. Maintain up-to-date knowledge of coding guidelines and standards to ensure compliance with NHS requirements.
4. Identify and correct any discrepancies or errors in patient records related to coding.
Summarising patient records
5. Review and summarise incoming patient records, ensuring all relevant medical information is is accurately captured and entered into the practices clinical system (EMIS)
6. Organise and file electronic and paper medical records appropriately.
7. Ensure the completeness and accuracy of patient records, supporting clinicians in delivering high quality patient care.
8. Liaise with other healthcare providers to obtain missing information where necessary.
Data quality and reporting
9. Assist in maintaining the integrity and quality of patient data, ensuring it is up to date and accurate.
10. Participate in regular audits of clinical coding and summarising practices to ensure compliance with internal and external standards.
11. Support the generation of reports and data amalysis for clinical and managerial use.
Person Specification
Experience
Essential
12. Some knowledge of medical terminology.
Desirable
13. A knowledge of EMIS Web or SystmOne.
14. Prior summarising experience in a GP surgery.
15. Knowledge of NHS policies relevant to Clinical Coding, Data Confidentiality, Information Governance, and Data Security policies.
Knowledge and Skills
Essential
16. Demonstrate computer proficiency and use Microsoft products ( Microsoft Office).
17. Excellent English language skills.
18. Strong attention to detail and accuracy in data entry and record keeping.
19. Able to time keep effectively, balancing workloads and priorities.
20. Ability to concentrate for long periods and be able to analyse complex sets of case notes.
Desirable
21. Ability to focus in stressful situations and work effectively under pressure.