Medical Records Summariser

Summarising existing patient records. Summarising new patient records to a high standard and within agreed timescales based on Practice procedures. Restructuring existing computerised notes. Produce a comprehensive electronic summary using SystmOne.

Maintaining structure when recording new information. Assisting GPs with queries relating to medical records. To work as a member of the clinical coding team, with responsibility for own areas, inputting coded data into the Patient Administration System. Coding from information gathered from a number of sources including patient notes, discharge forms, both manual and electronic, and other clinical information captured on a variety of sources.

This will also involve running computer searches on to identify missing information. To work with other administrators and healthcare professionals to provide a first-class service to our patients. To ensure clinical coding is recorded in a timely and accurate manner in accordance with both national and the Practice guidelines and standards. To maintain clinical coding skills and participate in internal and external training programmes as required for both refresher and specialist clinical coding courses and work toward a high standard of coding.

To extract, interpret and independently code clinical information from clinical letters and discharge summaries from hospitals and clinics To participate in quality improvement initiatives, identifying areas where the processes used within the coding function can be improved and assist in implementing.