Medical Summariser/Coder

Clinical Coding and Summarising • Summarise newly registered patient records and records received from other healthcare organisations. • Accurately extract and record relevant medical information into the patient record. • Apply appropriate clinical codes using SNOMED and other approved coding systems in accordance with practice protocols. • Ensure diagnoses, procedures, investigations, medications, allergies, immunisations and significant medical history are recorded accurately. • Review patient records for completeness and identify discrepancies requiring clarification. • Maintain accurate and clinically relevant problem titles within patient records. • Ensure coded information supports effective clinical care, disease management and reporting. • Assist with data cleansing and data quality improvement initiatives. • Support the maintenance of practice registers and disease-specific databases. • Identify and escalate concerns regarding clinical information where appropriate. Records Management • Organise and maintain electronic patient records in accordance with practice procedures. • Scan and attach documentation accurately to patient records. • Process incoming correspondence and ensure appropriate filing within clinical systems. • File, store and retrieve records as required. • Maintain an organised and efficient workflow to ensure timely processing of documents. Audit and Quality Improvement • Assist with data validation exercises and coding audits. • Support the practice in achieving QOF and other contractual requirements through accurate coding. • Participate in audits and quality improvement projects as directed. • Review coding accuracy and contribute to continuous improvements in data quality. • Support the development and implementation of coding policies, procedures and best practice guidance. • Assist in preparing data for reporting and performance monitoring purposes. Administrative Support • Provide administrative support to clinical and non-clinical teams when required. • Photocopy, scan and process documentation as necessary. • Support colleagues during periods of increased workload. • Maintain effective working relationships with all members of the practice team. • Undertake any other duties appropriate to the role as requested by management. Job description Job responsibilities Clinical Coding and Summarising • Summarise newly registered patient records and records received from other healthcare organisations. • Accurately extract and record relevant medical information into the patient record. • Apply appropriate clinical codes using SNOMED and other approved coding systems in accordance with practice protocols. • Ensure diagnoses, procedures, investigations, medications, allergies, immunisations and significant medical history are recorded accurately. • Review patient records for completeness and identify discrepancies requiring clarification. • Maintain accurate and clinically relevant problem titles within patient records. • Ensure coded information supports effective clinical care, disease management and reporting. • Assist with data cleansing and data quality improvement initiatives. • Support the maintenance of practice registers and disease-specific databases. • Identify and escalate concerns regarding clinical information where appropriate. Records Management • Organise and maintain electronic patient records in accordance with practice procedures. • Scan and attach documentation accurately to patient records. • Process incoming correspondence and ensure appropriate filing within clinical systems. • File, store and retrieve records as required. • Maintain an organised and efficient workflow to ensure timely processing of documents. Audit and Quality Improvement • Assist with data validation exercises and coding audits. • Support the practice in achieving QOF and other contractual requirements through accurate coding. • Participate in audits and quality improvement projects as directed. • Review coding accuracy and contribute to continuous improvements in data quality. • Support the development and implementation of coding policies, procedures and best practice guidance. • Assist in preparing data for reporting and performance monitoring purposes. Administrative Support • Provide administrative support to clinical and non-clinical teams when required. • Photocopy, scan and process documentation as necessary. • Support colleagues during periods of increased workload. • Maintain effective working relationships with all members of the practice team. • Undertake any other duties appropriate to the role as requested by management.