Linden Hall Surgery rr04yA5q
As a crucial part of the clinical operations, the successful candidate will ensure the integrity of patient data by applying correct clinical codes, summarizing key medical information, and facilitating communication among healthcare professionals. The position also involves participating in audits and quality checks to uphold high standards of detail and accuracy within patient records.
The Coder/Summariser plays a crucial role in maintaining accurate, organised, and up-to-date patient records within the GP surgery. The primary responsibilities of this role include processing incoming documents (e.g., letters, referrals, test results), accurately coding diagnoses and procedures, summarising patient records, and ensuring that relevant correspondence is forwarded to the appropriate team members such as GPs, GP Assistants, or other healthcare professionals. This position requires strong attention to detail, understanding of medical terminology, and proficiency in using electronic health record (EHR) systems.
The main duties of the Coder/Summariser role include:
- Processing Incoming Documents: Reviewing and accurately filing letters, test results, and reports into patient records.
- Clinical Coding: Assigning correct codes (e.g., SNOMED) for diagnoses, treatments, and procedures.
- Summarising Patient Records: Reviewing and summarising key clinical information (medical history, medications, etc.) in patient records.
- Forwarding Correspondence: Sending relevant documents and information to GPs, GP Assistants, or other team members as needed.
- Maintaining Data Quality: Ensuring accuracy, confidentiality, and compliance with data protection regulations.
About us
We are seeking a meticulous and detail-oriented Coder/Summariser to join our team. The primary responsibility of this role is to ensure that patient records are accurate, up-to-date, and coded correctly. The successful candidate will process incoming medical documents, assign clinical codes for diagnoses and procedures, summarise patient histories, and forward important information to relevant team members such as GPs and GP Assistants. This role is essential for maintaining the integrity of patient data and supporting the smooth running of clinical operations.
Key Responsibilities:
Processing Incoming Documents:
- Review and process hospital letters, consultant reports, test results, and other incoming correspondence.
- Accurately file documents into patient electronic health records (EHR) in a timely manner.
Clinical Coding:
- Apply the correct clinical codes (e.g., SNOMED) to diagnoses, treatments, and procedures as documented in patient records and correspondence.
- Ensure that all coding adheres to national and practice guidelines.
Patient Record Summarisation:
- Summarise patient medical records by reviewing past medical history, medications, allergies, and family history.
- Ensure new patient records are accurately summarised and updated in the EHR system.
Forwarding Correspondence:
- Forward relevant documents and correspondence to the appropriate team members, including GPs, GP Assistants, and other healthcare professionals.
- Flag urgent or important clinical information to the appropriate GP or clinician.
Maintaining Data Quality and Compliance:
- Ensure that patient records are accurate, complete, and compliant with GDPR and confidentiality requirements.
- Participate in audits and quality checks as needed to maintain high data integrity.
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