Medical Records Coder and Summariser

2 months ago

Calne, Wiltshire, United Kingdom Northlands Surgery Full time

About Northlands Surgery

We are a busy and growing healthcare organization in the heart of Wiltshire, seeking a skilled professional to join our team as a Medical Records Coder and Summariser.

Job Summary

The successful candidate will be responsible for administering clinical correspondence, ensuring that only relevant information is visible to healthcare professionals, while the rest is stored securely on patient records. This involves following a strict protocol to guarantee safety and accuracy.

Main Responsibilities

  • To ensure 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 the patient's clinical records into the practice computer system, working strictly in accordance with the practice notes summarising protocol.

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 and 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 peoples 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.

Professional / Personal 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 teams 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 peoples needs for alternative methods of communication and respond accordingly.

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