Medical Records Summariser/ Administrator

4 weeks ago

London, United Kingdom Tollgate Medical Centre Full time

Job summary

:

The practice is moving towardsbecoming a paper-light environment, and the main responsibilities of the post-holderwill be to summarise and read code relevant information from the patientsclinical records into the practice computer system, working strictly in accordancewith the practice notes summarising protocol.

Mainduties/key tasks:

Reviewing medical records and producingan accurate summary of the patients medical history.

Read coding the information accurately intothe 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. Provide administrative support to the Safeguarding Lead, as part of a team of Safeguarding Administrators. To learn and use knowledge of how to code and summarise various safeguarding documents from different agencies, and to manage the list of patients and review these regularly

This list is not exhaustive and may be subjectto change in line with the needs of the organisation

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:

Thepost-holder will assist in promoting and maintaining their own and othershealth, safety and security as defined in the practice Health & SafetyPolicy, the practice Health & Safety manual, and the practice InfectionControl 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:

Thepost-holder will support the equality, diversity and rights of patients, carersand 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:

Thepost-holder will participate in any training programme implemented by the practiceas 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:

Thepost-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-holdershould recognize the importance of effective communication within the team andwill 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 Person Specification

Experience

Essential

Experience in Summarising Medical Records Experience of working in General Practice Administration Skills

Desirable

Qualification in Medical Notes Summarising Experience in using EMIS Web

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