Clinical Coder

**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 code relevant information from patient’s clinical records into the practice computer system, working strictly in accordance with the practice notes summarising or clinical coding protocol.

**Main duties/key tasks**:

- 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
- Coding the information into the practice clinical system (**Emis Web Clinical System**)
- Auditing data collection standards in the practice
- Monitoring progress of notes summarising against practice targets
- Filing and retrieving paperwork
- Coding incoming clinical documents & electronic letters on to the clinical system
- Managing electronic GP2GP links and resolving degraded information
- Providing additional administrative support to workflow team (processing incoming documentation) or assisting with registration processes in times of need.
- Reviewing progress of summarising ensuring practice targets are achieved
- File and store medical records as required
- Photocopy documentation as required
- Scanning of patient related documentation and attaching scanned documents to patient’s healthcare records
- Answer incoming phone calls, transferring calls or dealing with the callers request appropriately
- Carry out system searches as requested
- Help admin team with regards to sending medical records to the Health Authority
- Help admin team to do call-recall of the patients when required.
- Maintain a clean, tidy, effective working area at all times
- Support all clinical staff with general administrative tasks as requested
- Effectively manage Emis Workflow online documents
- filing and coding appropriately
Any other reasonable task

**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, 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 free from hazards
- Actively reporting 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 holder’s role
- Undertaking periodic infection control training (minimum annually)
- Reporting potential risks identified
- Demonstrate due regard for safeguarding and promoting the welfare of children.

**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 de