Medical Records Summary jobs

General Practice Solutions (GPS) is one of the UK's leading providers of outsourced primary care support services, delivering high-quality clinical coding, workflow optimisation and administrative support to GP practices throughout England and the devolved nations.

The Clinical Coder plays a critical role in supporting GPS and its client practices by accurately reviewing, interpreting and coding clinical correspondence within General Practice clinical systems. The postholder will ensure patient records are maintained to the highest standard, enabling clinicians to make safe and informed decisions whilst supporting contractual, clinical and quality outcomes for each practice.

The role requires exceptional attention to detail, sound clinical judgement, the ability to interpret complex medical terminology and a commitment to maintaining the highest standards of confidentiality, information governance and patient safety.

Key Responsibilities

The postholder will be responsible for:

• Reviewing, interpreting and processing incoming clinical correspondence on behalf of multiple GP practices.
• Accurately applying SNOMED CT codes in accordance with NHS guidance and individual client practice protocols.
• Maintaining accurate and clinically meaningful electronic patient records.
• Updating active and historical problem lists where appropriate.
• Recording diagnoses, procedures, investigations, referrals and clinical observations.
• Updating demographic information where clinically appropriate.
• Processing hospital discharge summaries.
• Processing outpatient correspondence.
• Processing Accident & Emergency correspondence.
• Processing community and mental health correspondence.
• Processing pathology and diagnostic reports.
• Identifying documents requiring clinician review and escalating appropriately.
• Identifying urgent clinical information requiring immediate GP attention.
• Processing documentation in accordance with each client's Standard Site Rules (SSR).
• Maintaining productivity and quality standards agreed between GPS and its clients.
• Working across multiple GP practices, adapting to differing local workflows whilst maintaining consistent quality.
• Supporting business continuity by working across additional client sites when required.
• Reporting clinical incidents, quality concerns or potential patient safety issues immediately.
• Participating in quality assurance audits and competency reviews.

Clinical Responsibilities

The Clinical Coder will:

• Apply accurate SNOMED CT coding.
• Maintain problem lists.
• Record chronic disease diagnoses.
• Record acute diagnoses.
• Update long-term condition registers.
• Process pathology results where authorised.
• Process diagnostic investigations.
• Record surgical procedures.
• Record immunisations where appropriate.
• Record screening outcomes.
• Process referral outcomes.
• Escalate abnormal findings in accordance with client instructions.
• Identify safeguarding concerns and ensure these are managed appropriately.
• Ensure documents requiring GP action are routed correctly.
• Ensure documentation is filed accurately following completion.

Quality Responsibilities

The postholder is expected to:

• Deliver consistently high levels of coding accuracy.
• Meet contractual productivity targets.
• Maintain compliance with GPS Quality Assurance Framework.
• Participate in routine quality audits.
• Reflect upon audit findings and implement improvements.
• Participate in competency reassessments.
• Contribute to service improvement initiatives.
• Assist with developing and sharing best practice across the organisation.

Information Governance

The postholder must comply with:

• UK General Data Protection Regulation (UK GDPR).
• Data Protection Act 2018.
• NHS Confidentiality Code of Practice.
• Caldicott Principles.
• NHS Records Management Code of Practice.
• NHS Data Security and Protection Toolkit requirements.
• General Practice Solutions Information Governance Policies.
• Client confidentiality agreements.
• Information Security policies.

Patient confidentiality must be maintained at all times.

Person SpecificationEssential Experience

• Previous experience within NHS General Practice.
• Previous clinical coding experience.
• Experience using EMIS Web and/or SystmOne.
• Experience interpreting consultant correspondence.
• Experience processing GP workflow.
• Experience using SNOMED CT.
• Excellent understanding of primary care terminology.

Pay: £12.71 per hour

Experience:

• General practice: 2 years (required)
• SystmOne, EMIS Web or Docman: 2 years (required)

Licence/Certification:

• NHS Smartcard (required)
• NHS email address (required)

Work Location: Remote