Medical Report Typing jobs

Job Title: CLINICAL CODER / SUMMARISER

Responsible to: Assistant Practice Manager

GP lead for summarising

Practice Director

GP Partners

The main objectives of the job are:

To support the practice clinical team by ensuring the accurate and timely processing of clinical correspondence received, and by summarising patient records to a high standard, enabling clinical staff to access and understand patients’ medical histories efficiently.

The main duties are:

The following are the core responsibilities of the Clinical Coder / Summariser. There may be, on occasion, a requirement to carry out other tasks; this will be dependent on factors such as workload and staffing levels:

1. Accurately summarise new patient medical records in accordance with practice protocol and clinical coding standards by ensuring significant medical history is clearly and accurately recorded within the patient’s electronic medical record.

2. Review incoming clinical correspondence, including hospital letters, outpatient clinic letters, discharge summaries, diagnostic results and other relevant documentation. Identify and accurately code diagnoses, procedures, investigations, medications, allergies and other clinically relevant information using the appropriate coding systems.

3. Forward the clinical correspondence to the relevant GPs or any groups as per protocol.

4. Maintain accurate and up-to-date patient records, ensuring information is recorded consistently and in accordance with practice protocols.

5. Highlight abnormal or clinically significant results, diagnoses or information for review by the appropriate clinical staff, in line with practice protocol

6. Review records for duplicate, incomplete or inconsistent information and escalate queries to the appropriate member of the clinical or administrative team. Ensure clinical information is linked to medical conditions.

7. Ensure that the note’s summarised code is added when completed.

8. Maintain confidentiality and comply with information governance, GDPR, data protection and practice policies at all times.

9. Work closely with GPs, nurses and other members of the practice team to ensure relevant clinical information is accurately captured and readily accessible.

10. Assist with maintaining the quality and completeness of patient records and support practice data-quality initiatives.

11. Follow established protocols for handling sensitive, confidential and clinically important information and hiding this from view when relevant.

12. Keep knowledge of clinical coding systems, terminology and relevant practice protocols up to date with guidance from the summariser lead GP.

13. Participate in audits, training and quality-improvement activities relevant to the role.

In addition to the primary responsibilities, the Clinical Coder / Summariser may be requested to:

a. Support administrative staff, providing cover during staff absences

b. Scan patient-related documentation and attach scanned documents to patients’ healthcare records

Equality, Diversity & Inclusion

A good attitude and positive action towards ED&I create an environment where all individuals are able to achieve their full potential. Creating such an environment is important for three reasons: it improves operational effectiveness, it is morally the right thing to do, and it is required by law.

Patients and their families have the right to be treated fairly and to be routinely involved in decisions about their treatment and care. They can expect to be treated with dignity and respect and will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Patients have a responsibility to treat other patients and our staff with dignity and respect.

Staff have the right to be treated fairly in recruitment and career progression.

Staff can expect to work in an environment where diversity is valued, an

equality of opportunity is promoted. Staff will not be discriminated against

on any grounds including age, disability, gender reassignment, marriage and civil

partnership, pregnancy and maternity, race, religion or belief, sex or sexual

orientation. Staff have a responsibility to ensure that they treat our patients

and their colleagues with dignity and respect.

Safety, Health, Environment and Fire (SHEF)

This practice is committed to supporting and promoting opportunities for staff to maintain their health, well-being and safety. You have a duty to take reasonable care of health and safety at work for you, your team and others, and to cooperate with employers to ensure compliance with health and safety requirements. All personnel are to comply with the Health and Safety at Work Act 1974, Environmental Protection Act 1990, Environment Act 1995, Fire Precautions (workplace) Regulations 1999 and other statutory legislation.

Infection control policies are to be adhere to, which includes using protective equipment and clothing when required, following standard infection control precautions such as handwashing.

Confidentiality

This practice is committed to maintaining the highest standards of confidentiality in relation to patient information, staff information, and confidential corporate information. Patients entrust us to collect and retain sensitive information relating to their health and other matters pertaining to their care. Employees also entrust the practice with personal and employment-related information, and the practice holds commercially sensitive information relating to its business operations. All such information is provided and maintained in confidence and must be treated with the utmost respect.All patients, staff members, contractors, and stakeholders have the right to expect that their privacy and confidentiality will always be respected. Staff must maintain the confidentiality of patient records, employee information, and any confidential corporate information, including commercially sensitive information, business strategies, financial data, operational information, intellectual property, and other proprietary material. Such information must not be accessed, used, discussed, or disclosed unless authorised and necessary for legitimate clinical, employment, or business purposes.It is essential that, to meet our legal, regulatory, and contractual obligations and to maintain the trust of our patients, colleagues, partners, and stakeholders, all staff safeguard patient information, staff information, and confidential corporate information. Every member of staff is responsible for ensuring that confidentiality is always maintained and that information is protected from unauthorised access, use, disclosure, alteration, or loss.Complaints

Clinical Coder / Summarisers will provide patients who wish to complain with a copy of the practice’s complaints procedure and will explain how a patient should proceed if they want to complain face to face or in writing.

Quality & Continuous Improvement (CI)

To preserve and improve the quality of our output, all personnel are required to think not only of what they do but how they achieve it. By continually re-examining our processes, we will be able to develop and improve the overall effectiveness of the way we work. The responsibility for this rests with everyone working within the practice to look for opportunities to improve quality and share good practice.

This practice continually strives to improve work processes which deliver healthcare with improved results across all areas of our service provision. We promote a culture of continuous improvement, where everyone counts and staff are permitted to make suggestions and contributions to improve our service delivery and enhance patient care.

Induction training

On arrival at the practice, all personnel are to complete a practice induction programme; this is managed by the Office Administrator.

The clinical coder/summariser will also be responsible for inducting new members of the team, providing an overview of the role and ensuring that new team members understand their responsibilities, procedures and expectations in accordance with their specific role.

Learning and development

The effective use of training and development is fundamental in ensuring that all

staff are equipped with the appropriate skills, knowledge, attitude and competences to perform their role. All staff will be required to participate in and complete mandatory training, as directed by the training coordinator, as well as participating in the practice’s training programme. Staff will also be permitted (subject to approval) to undertake external training courses which will enhance their knowledge and skills, progress their career and, ultimately, enable them to improve processes and service delivery.

Staff are required to attend monthly PLTs when required which may involve a swap in shift pattern.

Collaborative working

All staff are to recognise the significance of collaborative working. Teamwork is essential in multidisciplinary environments. Effective communication is essential, and all staff must ensure that they communicate in a manner which enables the sharing of information in an appropriate way.

Service delivery

Staff at Lombard Medical Centre must adhere to the information contained within practice policies and regional directives, ensuring that protocols are adhered to at all times. Staff will be given detailed information during the induction process regarding policy and procedure.

Security

The security of the practice is the responsibility of all personnel. Staff must ensure that they remain vigilant at all times and report any suspicious activity immediately to their line manager. Under no circumstances are staff to share the codes for the door locks with anyone and they are to ensure that restricted areas remain effectively secured.

Professional conduct

At Lombard Medical Centre staff are required to dress appropriately for their role. Administrative staff will be provided with a uniform. Smart footwear to be worn at all times. (No Flip Flops)

All Lombard Medical Centre staff are required to be curtesy, polite and friendly to all staff, visitors and patients. Represent the surgery as professional and a warm welcome.

Physical and Mental Skills

· The post holder should be physically fit for the role with the necessary keyboard and IT skills.

· The post holder should be empathetic and skilled in listening, persuasion, and negotiation, and recognizes Care, Compassion, Courage, Competency, Communication, reliable, team player and Commitment in their role.

Mental Effort:

· Prioritising work is essential, as often many tasks are required to be undertaken simultaneously. The post holder is required to work under pressure and meet deadlines.

Emotional Effort:

· Potential distressing situations e.g. liaising and reading information with terminally ill patients and their carers/families. Exposure to vulnerable groups. The post holder will be able to manage their mental well being and report to management any issues immediately if experiencing mental health.

Physical effort:

· Prolonged periods of time spent in a sitting position at a computer screen.

Working Conditions

· To function effectively across a variety of environments

Other Duties

Clinical Coder / Summarisers may, from time to time, be asked to undertake other reasonable duties, with appropriate training and it expected that agreement to this will not be unreasonably withheld.

The Clinical Coder / Summariser will from time to time undertake work on special projects as agreed with the Practice Manager and/or GPs.

Pay: From £12.71 per hour

Benefits:

• Company pension
• Free parking
• Store discount

Work Location: In person