Summariser, Registration and Docman Administrator

To work as part of the administrative team under the guidance of the Practice Manager, providing comprehensive administrative support to the Practice. To summarise and code patient records into the Practice’s computer system to a high standard and in accordance with the Practice’s protocol. Undertake patient registrations and deductions, GP2GP transfers and manage all paperwork associated with these processes. Help with GP workload management by assisting with the management of all documentation arriving at the practice electronically and via post.

**Duties and responsibilities**

**Medical record summarising**:

- To review medical records and produce an accurate summary of the patient’s medical history, within the Practice’s protocols and agreed timescales.
- Enter Code information onto the Practice’s computer system.
- Use medical terminology knowledge to correct mistakes found in existing patient records.
- Adhere to and monitor progress of notes summarising against Practice targets, maintaining structure and protocols when recording new information.
- Be aware of specific Codes and associated records; following Practice protocols for recording, obtaining and filing patient records as appropriate e.g. child protection.
- Assist GPs and other Practice staff with queries relating to medical records.
- To participate in audits of data collection standards in the Practice.
- Liaise with internal/external departments or healthcare providers as required.

**Clinical Coding (both summarising and Docman admin)**:

- Analysing patient records and recording all the relevant information
- Examining records and documentation for missing information
- Assigning industry-recognised codes
- Collaborating with Physicians and other healthcare professionals to ensure information accuracy
- Ensuring that the healthcare facility complies with clinical coding guidelines
- Ensuring that all clinical codes are current
- Assigning and sequencing all codes for services rendered

**Registrations**:

- Ensure all registrations are kept up to date and completed in a timely manner
- Register all new patients, updating receipt of patient’s record
- Chase records for new patients if not received
- Monitor patient rejections by PCSE and determine why rejected and resolve issue.
- Update patient record amendments including name changes and address changes.
- Register temporary patients.
- Deduct patients leaving the surgery and ensure al records are dispatched to PCSE.
- GP2GP Transfers ensure completed appropriately and medication reviews undertaken by Pharmacy Team.

**Docman Administration**
- Scanning and filing of paper documents through Docman
- Clinical Coding - See previously.
- Workflow of coded documents to appropriate clinical staff based on actions required, including but not limited to doctors, pharmacists, reception and secretarial team.
- Filing blood test results not requiring clinical action

**Administration**:

- General Administration as required by the medical centre.

**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, to 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 and free from hazards
- Reporting potential risks identified

**Equality and Diversity**:
Thepost-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

- Acting in a way that recognises 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 o