Medical Records Summariser

Job summary

To be responsible for the readcoding of relevant information into patients electronic healthcare records on Victoria Park Health Centre's clinical system, adhering to the organisation coding policy.

Main duties of the job

a. Reviewing records and accurately producing a summary of the patients medical history

b. Accurately SNOMED CT coding data on the clinical IT system

c. Reviewing progress of summarising, ensuring practice targets are achieved

d. Review all clinical letters ensuring they are processed appropriately in line with extant protocols

e. File and store records as required

f. Photocopy documentation as required

g. Action all incoming correspondence, emails and mail in a timely manner

h. Scan patient related documentation and attach scanned documents to patients healthcare records

i. Input data into patients healthcare records as necessary

j. Conduct system searches as requested

k. Maintain a clean, tidy, effective working area at all times

l.Support all clinical staff with general administrative tasks as requested

About us

We are a large, dynamic, friendly practice consisting of 4 Partners, 13 Salaried GPs, 4 Clinical Pharmacists, 1 Pharmacy Technician, 2 Practice Nurses, 1 Nursing Associate, 1 Phlebotomist & 1 Social Prescriber. We serve 26,000 patients with a focus on clinical excellence and engagement with the modern NHS. Being located adjacent to the University of Leicester we do have a large student population.

We have a very strong team ethos and are looking for a committed and enthusiastic Medical summariser who can bring their own valuable knowledge and skills to our Practice. We are a teaching Practice with a regular allocation of trainees, we also demonstrate strong performance in QOF, CQC and we play a lead role within our PCN.

Job responsibilities

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

a. Reviewing records and accurately producing a summary of the patients medical history

b. Accurately SNOMED CT coding data on the clinical IT system

c. Reviewing progress of summarising, ensuring practice targets are achieved

d. Review all clinical letters ensuring they are processed appropriately in line with extant protocols

e. File and store records as required

f. Photocopy documentation as required

g. Action all incoming correspondence, emails and mail in a timely manner

h. Scan patient related documentation and attach scanned documents to patients healthcare records

i. Input data into patients healthcare records as necessary

j. Answer incoming phone calls, transferring calls or dealing with the callers request appropriately

k. Conduct system searches as requested

l. Maintain a clean, tidy, effective working area at all times

m. Support all clinical staff with general administrative tasks as requested

In addition to the primary key responsibilities, the Medical Summariser may be requested to:

a. Review and update the practice summarising policy as required (in conjunction with the management team

b. Partake in audit as directed by the audit lead

c. Support reception staff, providing cover during staff absences

d. Book appointments

Person specification

Experience

Essential

• Systmone experience
• Medical Records summarising experience
• Clinical coding experience