Clinical Coder & 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

• Process incoming clinical correspondence via electronic workflow systems
• Manage coding-related tasks within EMIS Web or equivalent clinical systems
• Support document management processes and workflow allocation where required
• Liaise with clinicians and administrative staff regarding coding queries

• Work collaboratively with clinicians, administrative staff and management
• Provide support and cover for colleagues during periods of absence
• Participate in Practice meetings and contribute to service improvement initiatives
• Demonstrate flexibility to meet the changing needs of the Practice

• Participate in mandatory and statutory training
• Undertake ongoing training in clinical coding and summarisation
• Maintain up-to-date knowledge of SNOMED CT and NHS coding standards
• Participate in annual appraisal and personal development planning

• Maintain a safe and tidy working environment
• Adhere to all Health & Safety and Infection Prevention and Control policies
• Report hazards, incidents or risks promptly
• Follow Practice security procedures

• Maintain strict confidentiality at all times
• Only disclose information in accordance with Practice policies and legal requirements
• Handle all data securely and appropriately

• Act in a way that supports equality, diversity and inclusion
• Respect the dignity, needs and beliefs of patients and colleagues
• Promote a non-judgemental and inclusive working environment

• Maintain high standards of work and accuracy
• Contribute to continuous improvement within the Practice
• Identify and report risks or issues relating to data quality or patient safety

• Communicate effectively with clinicians and colleagues
• Respond appropriately to queries regarding coding and summarisation
• Recognise and adapt to different communication needs

Essential

• Experience of administrative work in a healthcare or office setting. Experience handling confidential information. High level of accuracy and attention to detail.