Clinical Coder/summariser

Bridge Lane Group Practice
Job DescriptionJOB TITLE: Clinical coder and notes summariser
**REPORTS TO: Management Team**

**HOURS: up to 20 hours per week**

**SALARY: TBC**

**Job Summary**:
To read code all incoming letters via the electronic system and save to the patients’ record. To summarise and read code relevant information received from the Primary Care Support Service into EMIS Web. To ensure the practice has a robust system to record relevant clinical information.

**Responsibilities**:
**Letter Coding**
- Scan paper notes when appropriate
- Work in accordance with the Practice summarising/coding protocol.
- Read code all incoming medical letters received from the clinical team, either on paper or electronically
- Summarise, code and re-direct all letters, as appropriate received from various sources
- Check all computerised information is appropriately coded
- Check incoming letters for investigations ensuring all are entered appropriately

**Summarising**
- Reviewing medical records and producing an accurate summary of the patients’ medical history according to practice protocols.
- Read Coding the information into the practice clinical system in accordance with local and practice guidelines
- Filing and retrieving paperwork
- Monitor progress of notes summarising against practice targets
- Make clinicians aware of any medical problems needing follow up or immediate treatment or intervention.
- Alert clinicians to any reviews due for chronic disease monitoring.
- Inform the Doctor of any Child Protection case reviews / issues.
- Have working knowledge of IT systems: particularly EMIS Web, Microsoft Outlook and Mircrosoft Word

Admin
- Regularly checking the electronic inbox for all work outstanding
- Alert any other team members to issues of quality and risk
- Any other tasks, related to the above, as required by your line manager and or the Practice Manager

**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 will 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 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 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 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 team’s performance
- Work effectiv