Clinical Coder and Summariser

• Ensuring accurate and timely coding of clinical information onto patient records
• Summarising patient records in a clear, concise and clinically meaningful format
• Supporting clinicians with accessible, well-structured patient histories
• Maintaining data quality standards in line with NHS and Practice requirements
• Contributing to improved patient outcomes through accurate record keeping and reporting

• Extract relevant clinical information from hospital letters, discharge summaries and other correspondence
• Apply accurate clinical coding using SNOMED CT and other recognised coding systems
• Code diagnoses, procedures, medications, allergies and other relevant clinical data
• Ensure all coding is completed in a timely and accurate manner
• Identify and escalate any discrepancies or concerns within clinical documentation

• Review and summarise new patient records and existing records where required
• Produce concise and clinically relevant summaries of patient histories
• Ensure key information such as diagnoses, medications, allergies and significant past history is clearly recorded
• Maintain consistency and accuracy in summarisation standards
• Liaise with clinicians where clarification is required

• Maintain high standards of data accuracy and completeness within the clinical system
• Undertake regular data quality audits as directed
• Support the Practice in achieving QOF, IIF and other reporting requirements
• Ensure compliance with GDPR, NHS Confidentiality Code of Practice and Information Governance policies
• Maintain strict confidentiality at all times

Essential

• GCSE (or equivalent) in English and Maths (Grade C/Level 4 or above)
• Excellent attention to detail. Ability to work accurately under pressure. Good organisational skills. Ability to prioritise workload.
• Experience of administrative work in a healthcare or office setting. Experience handling confidential information. High level of accuracy and attention to detail.
• Reliable, methodical and conscientious. Professional and discreet. Team player. Ability to maintain confidentiality.

Desirable

• Clinical Coding qualification (e.g. AMSPAR or equivalent)
• Experience within NHS General Practice or Primary Care. Experience of clinical coding and summarising. Experience using EMIS Web or similar systems.
• Knowledge of SNOMED CT coding. Knowledge of EMIS WEB and DOCMAN. Understanding of QOF, IIF and NHS data requirements. Knowledge of medical terminology.