Experienced On-Site Medical Summariser & CoderNHS

Job summary

Claremont Clinic

Medical Summariser

Job Description

Hours: 25 Per Week

Claremont Clinic Grade: Depending on experience

Accountable to: Practice Manager/ GP for clinical issues

This post exists to improve the quality of patient care by maximising the use of information technology to enable the practice to meet the standards set by IMT.

Job Type: Part-time

Pay: Depending on experience

Expected hours: 25 per week

Schedule:

• Flexitime

Experience:

• Medical Records: 1 year (preferred)

Work Location: In person

Main duties of the job

Main Duties

Clinical Data Quality & Governance

• Enter patient data from hospital letters and discharge summaries into electronic records using EMISweb templates and appropriate read codes.
• Summarize and confirm the accuracy of new and old records within 8 weeks.
• Assist clinicians with read code usage to standardize data entry and support audits; update templates as needed.
• Conduct searches for chronic disease recall and manage patient group call/recalls.
• Provide regular reports (e.g., audits, recalls, workload) for clinical meetings as required.
• Monitor population health and Quality and Outcomes Framework (QOF) data, responding as needed.

Security, Confidentiality, and Governance

• Support practice security and confidentiality policies with the practice manager.

Training

• Assist with IT training needs analysis and provide training on IT systems, data quality, and confidentiality for team members.

Practice Improvement

• Propose and help implement improvements in information management and technology use.

Personal Development

• Stay updated in health informatics and attend relevant IT events.

Confidentiality

• Maintain confidentiality of practice and patient information, with disciplinary action for breaches.

This job description may change based on service needs.

Job description

Main Duties

Clinical Data Quality & Governance

1.1 Data entry from hospital letters, discharge summaries etc entered onto patients electronic record either manually and electronically. Use appropriate EMISweb template and read codes

1.2 Summarise the new and old medical records, within the required time-frame (8 weeks). Confirming that the patients manual & GP2GP (where appropriate) records match the data entry. Maintaining accuracy at all times.

1.3 To assist and advise in consultation with the clinicians with regard to using read codes for the purpose of facilitating uniform data entry and extracting data from the computer for the use of audits. To integrate read code updates into the practice standard templates as and when necessary.

1.4 To carry out regular searches to organise proactive recall for chronic disease management. To carry out timely call and recall for patient groups

1.5 To provide regular reports as and when necessary including for clinical meetings and in consultation with clinicians and act as directed. For example:

Audit/data/disease groups

Ad hoc recalls

Inadequate smear test

Prescribing data including for prescribing incentive scheme

Workload analysis

Referral analysis

Hospital activity analysis

Appointment analysis

1.6 To monitor population manager and Quality and Outcomes Framework (QOF) supplementary network services (SNS) and act on information /results accordingly

2. Security, Confidentiality and Information Governance

2.1 Assist in the maintenance and implementation of the practice policy on

Security and confidentiality in liaison with the practice manager and responsible partner

3. Training

3.1 Assist the practice manager and responsible partner in carrying out training

needs analyses on IT subjects giving due regard to health and safety

3.2 Provide training and support to practice team members, including student

locums and temporary staff on :

Assist Practice Manager in use of the practice IT as appropriate to the team

members roles.

Implementation of the practice security and confidentiality policy

Data entry and data quality, in liaison with external advisers including

software suppliers

4.Practice Development

4.1 Be pro-active in identifying and developing proposals for improving the

management of information and the use of current technology in the practice

and assist in the implementation of these developments.

5*Personal Development*

5.1 Keep up to date with developments in the rapidly changing field of health

informatics

5.2 Attend local and national IT events as decided by the practice

6. Confidentiality

6.1 To maintain confidentiality of all the practice affairs and the patients information a breach of which will be subject to the practice disciplinary procedures.

This job description is not intended to be definitive and is subject to change to meet service needs through discussion between the post holder and their manager.

About us

About Us:

At Claremont Clinic, we value individuals who are organized, adaptable, and personable, committed to delivering excellent customer service. Key attributes we are looking for include:

• Previous experience in medical/healthcare reception roles is preferred.
• Excellent communication skills with a clear and polite telephone manner.
• Ability to maintain confidentiality and discretion with patients.
• Experience in handling sensitive situations with empathy and professionalism.
• Strong teamwork and independent problem-solving abilities.
• Proficient in IT and general administration tasks.

Flexibility:Some flexibility is required to accommodate additional or alternative hours to cover colleagues during annual/sickness leave.

If you are ready to contribute to a supportive team environment and play a pivotal role in our community-focused clinic, we invite you to apply today.

Join Claremont Clinic and be part of our commitment to exceptional healthcare delivery.