Clinical Read Coder

7 months ago

Bristol, United Kingdom Mendip Vale Medical Group Full time

Mendip Vale Medical Group are looking to recruit further Clinical Read Coder to join our Bristol team (working in Sea Mills Surgery - this is not a remote role).

Working as part of a team the post-holder will assist in the processing of clinical documents. The post holder will be responsible for the accurate recording of paper, electronic and result documents into clinical records, including the coding of data and identification of relevant processing requirements in accordance with the Practice Read Coding Protocol.

The Clinical Read Coder will develop good working relationships with:

- GP, nurses and other surgery staff
- Patients
- External Organisations

**Key Responsibilities**:

- To support the Clinical team in the delivery of safe and efficient document management systems of patient medical records.
- Inputting patient information into the clinical medical systems.
- Coding electronic and paper related correspondence and results, accurately and consistently.
- Effective use of anatomical and physiological terms and knowledge to find relevant codes and link problems.
- Checking patient tasks and taking action to complete as required.
- Control all patient files and related admin to required quality standards and in line with information governance, GDPR and DPA regulations.
- Maintain accurate records.

**Other Responsibilities**:

- To understand performance targets and KPIs and proactively work with team to resolve any issues
- To support practice developments and change e.g. changed to service, policies, structure etc.
- To undertake any other duties commensurate with the post holder’s role as agreed with the management team.
- Attending training and events organised by the Surgery or other agencies, where appropriate.

**Communication**
- Adapt communication style and content to reflect the type of interaction.
- Ability to receive sensitive or contentious information and process appropriately.
- Promote positivity and effective working relationships within the team, other health care providers and other key partners to support an integrated approach to high quality patient care.

**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.
- Whilst performing the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, surgery staff and other healthcare workers. They may also have access to information relating to the Surgery as a business organisation. All such information from any source is to be regarded as strictly confidential.
- Information relating to patients, careers, colleagues, other healthcare workers or the business of the Surgery may only be divulged to authorised persons in accordance with the Surgery policies and procedures relating to confidentiality and the protection of personal and sensitive data.

**Health & Safety**
- Maintain the standards required for the health, safety and security procedures as defined in the Surgery Health & Safety Policy.
- Use personal security systems within the workplace according to Surgery guidelines.
- Identify the risks involved in work activities and undertaking such activities in a way that manages those risks.
- Make effective use of training to update knowledge and skills.
- Use appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards.
- Report potential & actual risks identified.

**Equality and Diversity**
- Support the equality, diversity and rights of patients, carers and colleagues, and challenge behaviours that fall below the standards required.
- Recognise the importance of people’s rights, interpreting them in a way that is consistent with Surgery procedures and policies, and current legislation.
- Respect the privacy, dignity, needs and beliefs of patients, careers and colleagues
- Behave in a manner which is welcoming to an individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

**Personal/Professional Development**
- Participate in any training program implemented by Mendip Vale as part of this employment.
- Identify personal development and training needs.
- Participate in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.
- Take responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.
- Participate in continuing education to maintain a contemporary level of professional knowledge and skill.

**Quality**
- Strive to improve quality within the Surgery.
- Assess own performance, ensuring competence, and being accountable for own actions, either

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