Clinical Coder

**Job title: Clinical Coder/Summariser**

**Reports to/responsible to: Pro-Active Care Team Manager**

**Working Hours: 20-24 hours per week, (flexible working considered)**

**Remuneration: £10.40 per hour**

**Job Purpose**

To ensure a high standard of accuracy in maintaining patient records for the Practice and to assist Practice staff in the effective delivery of care.

**Summary of Coding/Summarising Role in the Practice**
- To work calmly in a fast-paced environment with varying and occasionally conflicting time demands.
- To work within a large multidisciplinary team and understand the roles of each team member.
- To be flexible and willing to work their shifts to meet the needs of the business.
- Develop and maintain an in-depth knowledge and understanding of the services provided by the Practice and the wider health community.
- Assess own performance and take accountability for own actions, either directly or under supervision.
- Reviewing medical records and producing an accurate summary of the Patient’s medical history
- Participate in performance review and appraisals

**Main Duties**
- Sorting Patient records and letters in preparation for scanning/summarising
- Summarise and Read Code relevant information from clinical letters and patient’s clinical records into the Practice computer system (EMIS WEB), working strictly in accordance with the Practice notes & summarising protocol.
- Utilise relevant systems/equipment to be able to do the job to the best of your ability

Effectively manage own time, workload and resources.
**CODING AND ADMINISTRATION DUTIES**
- Input information from correspondence on to Patient Medical Records
- Read coding the information in the Practice clinical system (EMIS Web)
- Accurate filing of patient records and correspondence
- Photo copying and filing
- Maintenance of a high standard of medical records in line with Practice procedure
- All new notes to be labelled at point of registration
- Retrieval of patient records for surgery sessions as and when required
- Check GP rooms when trying to locate missing notes data/documentations
- Entering patient data in to computer system
- Receiving deliveries of medications / vaccines to the Practice in line with Practice procedure
- Maintaining administrative supplies in consulting rooms
- Stock checks
- Processing incoming and outgoing mail in line with Practice procedure
- Scanning patient documents into computer system
- Process incoming and outgoing medical records
- Log incoming notes on to request for notes session prior to passing to admin to log summaries
- Filing notes requested by GP / Medical Secretary
- Update request for notes session each week
- Assess patient entitlement to register within check boundaries
- Process recall letters - DNA letters to patients
- Contact patients to remind them of clinic appointments
- Process patient changes of registration information
- Support the work of the Medical Secretary and Business and Finance Manager in maintaining a high quality records system
- Participate in audit
- Prepare patient notes for summarising

**Outcomes**
- Timely management of clinical information received in practice.

**Confidentiality**
- While seeking treatment, patients entrust us with sensitive information 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 role, the post-holder will have access to confidential information relating to patients, 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.

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- To work in accordance with all Practice written protocols.

**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, policies, and current legislation.
- Respecting the privacy, dignity, needs and beliefs of patients, carers, and colleagues.
- Behaving in a manner which is welcoming, non-judgmental and respectful of circumstances, feelings, priorities, and rights.

**Safeguarding**

The Thornton Practice is committed to safeguarding and promoting the welfare of all. The post
- holder will be expected to share this commitment.

**Personal/Professional Development**

The post-holder will participate in any training programme implemented by the Practice as part of this employment.

**Important Note**

**Person