Medical Records Summariser/ Administrator

SUMMARISER/ADMINISTRATOR- JOB DESCRIPTION TOLLGATE MEDICAL CENTRE JOB TITLE: MEDICAL RECORDS SUMMARISER/ADMINISTRATOR REPORTS TO: HR & Operations Manager HOURS: 37 hours per week Job summary: 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 the patients clinical records into the practice computer system, working strictly in accordance with the practice notes summarising protocol. Main duties/key tasks: Reviewing medical records and producing an accurate summary of the patients medical history. Read coding the information accurately into the practice clinical system Auditing data collection standards in the practice Monitoring progress of notes summarising against practice targets Filing and retrieving paperwork Managing electronic summary care record data. Recording immunisation data and dealing with immunisation data requests.

Dealing with documentation that arrives via the post/internally/externally and electronically. Scanning as required. Receiving medical records into the practice and storing and coding them appropriately. Faxing documents as required.

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, the practice Health & Safety manual, and the practice Infection Control policy and published procedures. This will 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 Actively reporting of health and safety hazards and infection hazards immediately when recognised Keeping own work areas and general / patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the job holders role Undertaking periodic infection control training (minimum annually) 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. 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 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