Clinical Coder & Summariser
- NHS
- Part Time
- Brownhills
- Negotiable
Job Description
Job summary
We are offering an exciting opportunity for a Clinical Coder & Summariser to join our successful & progressive group of five practices in the Walsall area.
You will be responsible for reading electronic & hard copy correspondence; coding or linking diagnoses to record on patients records, coding relevant investigations, and actioning requests as necessary.
The role also involves compiling a comprehensive, chronological medical summary from the patient record and inputting into electronic records utilising the Good Practice guidelines & Umbrella Medical Summarising Protocol. Moving forwards, you will have the chance to be involved in the Lloyd George envelope digitisation of notes project.
The successful candidate will ideally have a clinical background but applicants will be considered if they have previous experience of working in a clinical setting or of using clinical coding systems.
The successful candidate will also have
- Effective communication skills
- Good IT skills (EMISweb experience an advantage)
- Knowledge of medical terminology and read code systems
- Ability to use own judgement and work without direct supervision to determine workload priorities and achieve targets/deadlines
- High level of attention to detail
Main duties of the job
You will be responsible for reading electronic & hard copy correspondence; coding or linking diagnoses to record on patients records, coding relevant investigations, and actioning requests as necessary.
The role also involves compiling a comprehensive, chronological medical summary from the patient record and inputting into electronic records utilising the Good Practice guidelines & Umbrella Medical summarising protocol. Moving forwards, you will have the opportunity to be involved in the Lloyd George envelope digitisation of notes project.
About us
Umbrella Medical is a growing partnership with a very strong emphasis on providing high quality accessible care. We are currently CQC OUTSTANDING (2 practices) and continue to build on that foundation. We recognise that General Practice is changing and in order to continue to provide excellent care we are offering the above position.
Job responsibilities
Major duties and responsibilities of the post:
Summarising:
From patient records identify relevant medical events, read code and log into the computer, categorising into significant or minor events
Sort Lloyd George cards or A4 records into date order; retrieve relevant information, read code into computer and tag cards
Place letters and reports into date order, retrieve relevant information, code to computer and tag
Follow up missing records with previous GP and Medical Records Department
Place appropriate information into relevant templates
Follow up on any defaults i.e. cervical screening, asthma checks, diabetic reviews, retinopathy screening, medication reviews and immunisations and contact reception to book if required
Update new diabetic patients to the diabetic retinopathy screening service
Report learning disabilities patients to the Learning Disabilities Nursing Team to ensure that they are known to service and coded as needing an annual LD review and contact reception to book if required
Prioritise workload as necessary, ensuring children, vulnerable adults or those with significant health problems are summarised first
When summarising a child check household in case of possible child/ adult safeguarding concerns
Ensure a childs household address matches exactly to that of Parent/Carer or any other adult living at the same address
Report any child or adult safeguarding concerns to the appropriate lead/clinician
Ensure any extraneous material in records is shredded prior to disposal
Filing and retrieval of paperwork
Ensure pregnant patients are coded as pregnant and ensure they have a midwife appointment booked
Record and date childrens current school from new patients questionnaire
Verify forms that express dissent to the: Summary Care Record dataset upload, Care Data Service and data to and from Health and Social Care to be used and code as required
Obtain any past family medical history from records and code to computer appropriately
Record any patient allergies identified appropriately
Monitoring the progress of notes summarising against Umbrella Medical targets/deadlines
Process and verify the GP to GP transfer of electronic and paper records for new patients to the practice, ensuring outstanding referrals and results are actioned appropriately
Ensure that medications transferred via GP to GP are stopped and recorded and if needed a new patient medication review is booked by reception
Verify that all records belong to the patient, and if not return to the appropriate organisation
Post Reading
Read electronic and hard copy of incoming correspondence; code or link diagnosis to record in patients problem page, code relevant investigations, and action requests as necessary
Ensure relevant investigations necessary for a diagnosis such as MRI/ CT scan are recorded when coding problems such as TIA/Stroke/STEMIs
Send tasks as relevant i.e. book appointment with doctor to reception
Send reports/results as requested
Check addresses are correct on clinic letters and notify reception if different to the address we hold to confirm with the patient and appropriate action can be taken
Inform the practices Cancer Champion of a new diagnosis of cancer so the patient can receive the appropriate support
Tidy up problem page/patient warning whenever possible by removing unnecessary or outdated information
Ensure children subject a to child protection plan warning is removed when necessary by recording corresponding code when the child is no longer on register
Add code/note to all other family members when a child is subject to a child protection plan or there is domestic abuse in household
Code and monitor childrens DNA and vulnerable adults at hospital appointments, and inform the appropriate clinician/lead if necessary
Auditing on an adhoc basis historical codes as required to ensure validity of coding
Notify relevant summariser/lead on GSF if a patient is end of life so they can be put on the GSF register
Any other duties considered by Umbrella Medical to be appropriate to the post
Person Specification
Qualifications
Essential
- Good Standard of education including GSCE pass grade in English Language and Maths
Desirable
- Nursing/medical qualification
Experience
Essential
- Experience of working in General Practice or the NHS
- Experience of using a clinical system
Desirable
- Previous experience of working as clinical summariser/coder of medical notes within the NHS
- Experience of working with EMIS Web
Knowledge & Skills
Essential
- Medical Terminology
- Understanding of the read code system/SNOMED coding
- Effective Communication Skills
- Analytical skills
- Excellent telephone manner
- Good IT Skills
Desirable
- Able to multi-task
- High level of computer literacy
Personal Competencies and Qualities
Essential
- Understanding, acceptance and adherence to the need for strict confidentiality.
- Ability to use own judgement and work without direct supervision to determine workload priorities.
- Ability to recognise the severity of different medical conditions and the urgency of the actions they require
- Ability to work as part of a multi skilled team.
- Methodical approach to work and ability to meet targets/deadlines
- Self-motivated
- Willing to take part in training and personal development
- High attention to detail
- Friendly and articulate
- Smart appearance
Desirable
- Able to cope well with working in a changing and demanding environment
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Employer details
Employer name
Umbrella Medical
Address
Mossley Fields Surgery
3 Fisher Road
Walsall
WS3 2TA
