Medical Summariser

6 months ago

St Albans, United Kingdom Lodge Health Partership Full time

**_Working together effectively to enhance the health and wellbeing of our communities _**

**JOB DESCRIPTION**

**TITLE**:
Medical summariser

**REPORTS TO**:
Facilities and IT Manager

**ACCOUNTABLE TO**:
Practice Business Manager

**KEY RELATIONSHIPS**

Reception and administration team

Patients

Partners

Clinical teams

Management team

**LOCATION**:
The Lodge Surgery, Highfield Surgery and Redbourn Health Centre

**SUMMARY OF POSITION**:
The Lodge Health Partnership maintains excellent electronic medical records and the main responsibility of this post within the Information Team is to ensure that both new and existing patient records are up-to-date and accurately coded and recorded on EMIS, the Practice computer system. This will be carried out in accordance with the Practice Summarising Protocol. In addition, this post is required to carry out data searches and audits, and support patient recall systems and service campaigns.

**SPECIFIC RESPONSIBILITIES**
- Scan, input and accurately code daily communications to record appropriate medical information in patient records.
- Prioritise and distribute, via electronic document management, appropriate patient information and correspondence.
- Ensure safeguarding issues are raised with the Practice Safeguarding Lead or Practice Manager.
- Ensure any other important correspondence is prioritised and distributed to the appropriate people in accordance with training and guidance.
- Manage the incoming transfer of electronic and paper records for new patients.
- Produce and maintain an accurate coded medical summary.
- Ensure that all essential history held in paper records is recorded in the electronic records.
- Accurately code and prioritise information to aid:

- Patient consultations, referrals and prescribing.
- Practice audit and targets.
- Patient recall systems for screening, immunisations, chronic disease management or any other relevant purpose.
- File and retrieve information as required.
- Summarising and reconstituting records in cases of adoption or gender re-assignment where a new NHS number and record is required.
- Redacting paper records if necessary (adoption / gender reassignment cases)
- Hiding summarises from previous surgeries and digitised paper records so they are not available unless as part of a SARS record.
- Utilising a range of computer software may be required to deliver the requirements of the post including EMIS, Open Exeter and more. Training will begiven.
- Ensure clinical summaries and paper notes are obtained from previous surgeries to complete electronic records where GP2GP integration has failed. This may involve using PCSE clinically urgent record recall system and / or partial record missing.
- For newly registered patients in particular this may involve contacting previous surgeries for an urgent clinical summary / documents to aid patient treatment or medication authorisation and review.

**ADDITIONAL RESPONSIBILITIES (For all Staff)**

In addition to the specific responsibilities set out within this job description, The Lodge Health Partnership has the following expectations of all staff:
**Customer Care**

The post-holder must act in such a way to promote a positive image of The Lodge Health Partnership at all times. It is expected that all staff members reflect the values of the organisation:
**QUALITY**:

- Clinical quality; quality of our service from start to finish; quality of our environments

**HELPFUL AND EMPATHETIC ATTITUDE**:

- Respectful, friendly, adaptable, caring and understanding behaviours with patients and each other.

**MAKING IT EASIER** - easier to get help, information, to book, to work and use technology solutions

**COMMUNICATION**:

- with patients and with each other. Open and honest, one team culture, with third parties and communities.

**Confidentiality**:

- In the course of seeking treatment patients entrust us with and 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.

**Information Governance**

All staff have a personal responsibility to ensure that person identifiable, confidential or sensitive information is processed in line with the Data Protection Act (2018),

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