Key working Relationships Finance Department, Information Department, IT Department, Clinicians, other Medical and Nursing staff, Ward staff and Healthcare Records staff. Main Responsibilties To extract relevant information from case notes/source documents to enable the coding of clinical activity. To critically analyse the data from all available sources relevant to the episode of care and interpret this information using the current classifications (World Health Organisation ICD10 and Office of Population Censuses and Surveys version 4), applying national and international rules and conventions whilst maintaining accuracy and completeness of coding. This will require the use of initiative and judgment to reconcile the given diagnoses and to integrate new procedures. To be responsible for accurate completion of all in patient and day case episodes ensuring that all relevant information is coded, referring where necessary in complex cases to the Clinical Coding Manager. To be responsible for meeting existing targets of completed coding and to ensure that the agenda for Payment by Results (PbR) is achieved through accurate and timely coding. To take responsibility for entering the coded clinical information onto the Patient Administration System (PAS). To identify missing activity for all specialities by producing daily/weekly lists of uncoded activity, using the information available from electronic patient records, discharge summaries, x-ray reports and histology reports. To report any discrepancies in data provision to the relevant Ward/Department and the Clinical Coding Manager. To check and amend coded data regarding patient episodes on the Patient Administration System ensuring that all the information is accurate and complete. To develop and maintain good links with clinical staff to improve and ensure good quality and depth of clinical coded data, amending clinical coding where necessary. To ensure that medical case notes are kept in good order and booked out to the correct Department after the coding episode has been completed. To assist with the preparation of Information Governance and PbR Audits by pulling and returning medical case notes to and from the Records Library. To attend the mandatory external NHS 18 day Clinical Coding Foundation Course. To work towards the national accredited clinical coding ACC qualification or the Trust internal assessment. To take responsibility for maintenance and improvements of clinical coding knowledge by attendance at the mandatory external NHS two yearly Refresher Training Course and other speciality courses in line with Department training plans. To be responsible for identifying personal training and development needs through appraisals in line with Trust policies. To provide codes to the Information Department to enable data analysis for statistical and research purposes. To provide coding information to other Departments within the Trust as and when required. To provide support and cover as required within the Department. To attend meetings as requested and within own remit. To promote the professional image of the Clinical Coding Department throughout the Trust and to ensure that all duties are carried out in a professional manner. To main confidentiality at all times in line with the Data Protection Act.