Clinical Coder and Medical Note Summariser
5 months ago
The **Central Admissions Team** (CAT) based at **The Light Surgery** in **Leeds** are looking for a forward thinking **Clinical Coder and Medical Note Summarise**r.
The post holder will be responsible for reviewing new and existing medical records and patient information. They will summarise and read code relevant information from patient’s clinical records into the practice clinical system, to provide the clinical staff with an accurate and easily accessible electronic summary of a patient's medical history.
The post holder will ensure that the records comply with legal, regulatory and ethical requirements, working strictly in accordance with the Notes Summarising Protocol.
Monitoring progress of notes summarising against practice targets and monitoring patient call and recall systems will form part for the role in addition to basic administration work such as filing and retrieving paperwork.
- Sort patient records and letters in preparation for summarising
- Ensure that all incoming patient records are collated, tidied, accurately summarised and stored on the patient’s computerised medical record and relevant information is coded;
- Reviewing medical records (electronic and hard copy) and producing an accurate summary of the patient’s medical history.
- Forward to appropriate member of staff if necessary and seek advice from clinical staff regarding medical terminology and/or medical information or coding if unsure.
- Review any GP2GP transfer of medical records and ensure they are accurately recorded and coded as per practice protocol
- Ensure all documentation coming into the practice is dealt with in a timely manner; sort and date stamp all incoming patient related mail.
- Inform GPs and/or Administration staff of any relevant information that may require recall or follow-up.
- Follow practice protocols to ensure consistent and efficient processing of patient medical record coding
- Read Coding the information onto the sites clinical system
- Code clinical information onto patient computerised record.
- Support any of our sites in the area with the notes summarising, if required
- Deal with any queries or question relating to summarising and/or coding of medical records both from internal or external sources.
- Be able to locate patient’s medical records as needed by the clinical and non-clinical staff and request from the relevant authority as required.
- Carry out administrative tasks relating to patient records, including filing, sorting and document management.
- Be willing to travel to and work from other OMG sites in the area to support with the summarising, if required
- Prepare reports as necessary; any other duties as needed for the good of the practice.
**System used**: SystemOne
**Why join us?**
**Our Benefits;**
- 33 days annual leave (inc. Bank holidays), which rises with length of Service (pro rata for part time)
- Extra day of leave per year for work anniversary
- Enhanced Maternity, Maternity Support (Paternity), Adoption pay
- Special and Significant Event Leave
- Family friendly employment policies
- Continued personal and professional development
- Participation in OMG’s refer a friend scheme
- Internal wellbeing support through OMGs Wellbeing Advisors
- Employee Assistance Program run by awarding winning Health Assured
- Eye care scheme - free eye test plus a contribution towards glasses
- Cycle to work scheme
- Access to NHS Discounts
**Working at OneMedical Group**
Our teams at OneMedical Group, whether working for OneMedicare, OneMedical Property or within our Support Centre, all come together, collaborate, share ideas and have fun The team is made up of forward thinking and people centred individuals with different skills and abilities, where you can learn from each other and make a positive and valuable impact.
**Who we are**
OneMedical Group is a family run organisation with our co-founders still involved in supporting our teams to be at their best. We have an ambitious strategy and mission, one that is shared and supported by our whole Group. The Group was started with the vision of delivering healthcare differently, and to make a real difference to the communities that we work with.
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