Medical Notes

1 month ago

Wolverhampton, United Kingdom Prestbury Medical Practice Full time

**Job Summary**:
The Practice is moving towards becoming a paper-light environment, the main responsibilities of the post-holder are for the day to day supervision and management of all medical records summarising staff ensuring that notes are summarised and read coded with relevant information from patient’s clinical records into the Practice computer system, working strictly in accordance with the Practice notes summarising protocol.

**Main Duties/Key Tasks**:
Induction and training of all new staff to agreed standards
- Ensure adequate staffing levels to maintain workflow any shortfalls report to practice Manager.
- 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.
- Read Coding the information into the Practice clinical system
- Auditing data collection standards in the Practice
- Monitoring progress of notes summarising against Practice targets
- Monitoring patient call and recall systems
- Filing and retrieving paperwork

**Practice Values**

To demonstrate and provide evidence of the Practice Values, these are:

- Provide a professional service
- Working together as one
- Respect for each other

**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 carer’s, 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

To ensure the safety and security of patient records or data by storing them in a lockable cabinet or cupboard when no longer required or at the end of your working day.

**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**:
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 and policies, and current legislation

Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues

Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

**Personal/Professional Development**:
The post-holder will participate in any training programme implemented by the Practice as part of this employment, such training to include:

- Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
- Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work

**Quality**:
The post-holder will strive to maintain quality within the Practice, and will:
Alert other team members to issues of quality and risk

Assess own performance and take accountability for own actions, either directly or under supervision

Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team’s performance

Work effectively with individuals in other agencies to meet patients’ needs

Effectively manage own time, workload and resources

**Communication**:
The post-holder should recognize the importance of effective communication within the team and will strive to:

- Communicate effectively with other team members
- Communicate effectively with patients and carers
- Recognize people’s needs for alternative methods of communication and respond accordingly

**Contribution to the Implementation of Services**:
The po

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