Clinical Coder and SummariserNHS

Job summary

Job Summary

The Clinical Coder and Summariser plays a vital role in maintaining accurate, high-quality patient records. The postholder is responsible for coding and summarising clinical information from patient records, hospital correspondence and other clinical documentation onto the Practice clinical system.

Working in line with Practice policies, NHS Digital guidance and information governance requirements, the role supports safe clinical care, accurate data reporting and effective population health management.

The role requires excellent communication skills, sound judgement, empathy, confidentiality and the ability to remain calm whilst managing competing priorities within a busy healthcare environment.

Main duties of the job

Main Purposes

To support high-quality patient care by:

• 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

Job description

Principal Duties and Responsibilities

Clinical Coding

• 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

Summarising Patient Records

• 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

Data Quality and Information Governance

• 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

About us

Revel Surgery is a friendly, well-established GP practice in a lovely rural location on the outskirts of Rugby, serving a diverse and supportive patient population. The practice is located on one site incorporating a dispensary. With nearly 8,000 patients, we are proud of our reputation for delivering high-quality, patient-centered care within a welcoming and inclusive environment.

Revel Surgery offers an excellent opportunity to develop your career in primary care while enjoying a rewarding and fulfilling working environment.