Medical Records Assistant

**JOB DESCRIPTION**

**Job Title**:Medical Records Assistant

**Accountable to**:Medical Records Co-Ordinator

**Key Relationships**:Reception, Medicines Management, Medical Secretary and Recall Teams, GPs, Primary Care Support England

**Salary**: LMP Grade 2

**Interviews to be held on Wednesday 13th December.**

**Job Summary**:
The post-holder will summarise and read code relevant information from and into patients’ clinical records, working strictly in accordance with the agreed protocol.
The post-holder will be responsible for the management of incoming correspondence in relation to medical records.

The post-holder will be responsible for the coordination of patient registrations and amendments to patient records in-line with the agreed policy.

The post-holder will be responsible for the administration of medical records arriving in the practice and those being returned to the agency.

**Key Duties/Responsibilities**
- 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
- Monitoring progress of notes summarising against practice targets
- Filing and retrieving paperwork
- Electronic filing and work-flowing of correspondence in line with agreed protocols
- Registration of patients into the EMIS system
- Deduction of patients from the EMIS system
- Administration of the registration links portal
- Administration of FP 69s
- Administration of amendments to records
- Receipt of medical records and associated administration
- Coordinate the transportation of medical records within Lancaster Medical Practice

**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 and Diversity**:
The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

- Acting in a way that recognises the importance of people’s rights, interpreting them in a way that is consistent with the Practice policies and procedures, and current legislation
- Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues
- Behaving in a manner which is welcoming to 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 their own personal and/or professional development
- Taking responsibility for their 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

**Safeguarding**:
LMP is committed to safeguarding and