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Medical Records Administrator

1 month ago

Peterborough, United Kingdom The Deepings Practice Full time

**About us**:
The Deepings Practice is a large practice based in Market Deeping with a branch site at Glinton, we serve over 24,000 patients. The Deepings practice has a large team of clinical and non-clinical staff lead by seven partners and a full senior management team. We have a CQC score of Good and strive for excellence in all areas of patient care. We have a strong focus on health promotion and personalised care, supporting patients to make informed decisions about their health and social care. We are a dynamic, friendly, and supportive team with experience in training GPs and other healthcare professionals.

**Job Summary**:

- To ensure that all incoming and internal patient correspondence is stored on/in the patient’s medical record and relevant information is coded.
- To be able to locate documents as needed by the clinical and non-clinical staff.
- To carry out administrative related tasks as delegated by the doctors and non-clinical staff.
- To summarise and read code relevant information from patient’s clinical records into the practice computer system, working strictly in accordance with the Lincolnshire wide Standardised Read Code List and with Practice Protocol.

**Main Duties**:
**Summarising**:

- Receiving medical records and risk assessing those who need doing urgently.
- Sorting patient records and letters in preparation for summarising as required in accordance with current Practice Policy.
- Reviewing medical records and producing an accurate summary of the patient’s medical history.
- Read Coding the information into the practice clinical (SystemOne) system:

- Working towards a 6 month target to summarise and code high risk patients such as safeguarded patients, elderly, children and babies.
- Review GP2GP incoming notes and code where necessary taking into consideration degrades and review of duplicated allergies/sensitives.
- Filing and retrieving paperwork as appropriate.
- Inputting immunisations
- Contact other practices to request missing information.

**Scanning**:

- Using the practice Workflow procedures, scan and/or attach patient-related documents onto their medical record using read codes as agreed by the Practice policy/GP Lead.
- 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, where possible, 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 dispose the documents in line with surgery procedures.

**Coding**:

- Identify relevant clinical information contained in patient correspondence
- Code or free text the clinical information onto the patient record
- Deal with queries relating to coding.

This is not an exhaustive list.

**Disclosure and Barring Service Check**:
**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 & 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 ind

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