Medical Summariser/clinical Coder

**Job Title: Medical Summariser/ Clinical Coder**

**Location: Spring Hill Practice**

**Reporting to: Practice Manager**

**Hours: 37.5 Hours**

**Pay: Depending on Experience**

JOB PURPOSE

The practice is moving towards becoming a paper-light environment, and the main responsibilities of the post-holder will be:

- To summarise and read code relevant information from patient’s clinical records into the practice computer system, working strictly in accordance with the practice notes summarising protocol.
- To review incoming mail and process as described by practice policy/process for inputting data from said mail and ensuring all record summaries remain up to date and accurate

MAIN DUTIES AND RESPONSIBILITIES
- To be aware of national, local and practice quality standards for chronic disease management codes.
- To ensure staff are aware of the importance of maintaining disease registers and assist in the validation process.
- To assist in the production of information for clinical audit as requested by the clinicians.
- 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 according to the practice summarising policy
- Read/SNOMED coding the information into the practice clinical system
- Auditing data collection standards in the practice
- Monitoring progress of notes summarising against practice targets
- Monitoring patient call and recall systems
- Filing and retrieving paperwork
- Coding incoming correspondence according to practice protocol.
- Reviewing incoming medical records for new patients joining the practice and producing an accurate summary of the patients’ medical history on the computer clinical system.
- Use accurate Read coding/SNOMED to input information on to the records
- Auditing data collection standards in the practice.
- Filing and retrieving paperwork
- Scan patient-related documents in to their medical record using read/SNOMED codes as agreed by the clinical team
- Identify relevant clinical information contained in patient correspondence
- Code or free text the clinical information on to the patient record
- Deal with queries relating to coding

Clinical Governance and Performance/Quality Management
- Attend primary health care team meetings as instructed; implement agreed actions as directed.
- Assist with the preparation for any external inspection visits.
- Participate in significant event process.
- Ensure that the Practice performs to standards, both administrative and clinical, as may be required under the terms of the APMS or any other contracts

**Other duties**

Be self-sufficient in day-to-day administration.

Continuously review and evaluate own performance to identify strengths and areas of development, and undertake appropriate activities for skills and professional development.

Act at all times within and uphold the Practice’s protocols and procedures including Confidentiality, Equal Opportunities and Health & Safety, and ensure they are adhered to in all functions of the post.

**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, eit