Medical Records Clerk

6 months ago


Bristol, United Kingdom Tyntesfield Medical Group Full time

Follow practice protocols to ensure consistent and high-quality care is provided to our patients Carry out administrative tasks relating to patient records, including filing, document management, and ensuring patients can access reports and prescriptions and that they are easily accessible. Summarising Culling and sorting patient records and letters in preparation for summarising. Reviewing medical records and producing an accurate summary of the patient's medical history. Clinical coding the information into the practice clinical system.

Auditing data collection standards in the practice. Monitoring the progress of notes summarising against practice targets. Monitoring patient call and recall systems. Filing and retrieving paperwork.

Extraction of necessary data from clinical correspondence and input into the electronic patient records. File copies of hospital referrals/letters. Scan summaries, letters, and relevant correspondence into patient's notes. GP2GP transfer of patient records.

Ensure security of data at all times. Enter child protection alerts on all relevant patients following practice protocol. Scanning duties Collect and sort all incoming patient-related mail. Scan patient-related documents onto their medical record using SNOWMED to add codes as agreed by the clinical team.

Add any additional information about the source of the document. Forward the document to the doctor or nurse who initiated the referral or who is most appropriate to receive the information. Ensure incoming letters are scanned onto the patient record within a 48/72-hour timescale. Scan all internal paper documents onto the relevant patients' record and then store the documents in line with surgery procedures.

Coding Identifying relevant clinical information contained in patient correspondence. Code or free text the clinical information on to the patient record. Deal with queries relating to coding.


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