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Clinical Coder & Summariser
| Posting date: | 09 April 2025 |
|---|---|
| Salary: | Not specified |
| Additional salary information: | Negotiable |
| Hours: | Full time |
| Closing date: | 23 April 2025 |
| Location: | Walsall, WS3 2TA |
| Company: | NHS Jobs |
| Job type: | Permanent |
| Job reference: | A0260-23042025 |
Summary
Major duties and responsibilities of the post: Summarising: From patient records identify relevant medical events, read code and log into the computer, categorising into significant or minor events Sort Lloyd George cards or A4 records into date order; retrieve relevant information, read code into computer and tag cards Place letters and reports into date order, retrieve relevant information, code to computer and tag Follow up missing records with previous GP and Medical Records Department Place appropriate information into relevant templates Follow up on any defaults i.e. cervical screening, asthma checks, diabetic reviews, retinopathy screening, medication reviews and immunisations and contact reception to book if required Update new diabetic patients to the diabetic retinopathy screening service Report learning disabilities patients to the Learning Disabilities Nursing Team to ensure that they are known to service and coded as needing an annual LD review and contact reception to book if required Prioritise workload as necessary, ensuring children, vulnerable adults or those with significant health problems are summarised first When summarising a child check household in case of possible child/ adult safeguarding concerns Ensure a childs household address matches exactly to that of Parent/Carer or any other adult living at the same address Report any child or adult safeguarding concerns to the appropriate lead/clinician Ensure any extraneous material in records is shredded prior to disposal Filing and retrieval of paperwork Ensure pregnant patients are coded as pregnant and ensure they have a midwife appointment booked Record and date childrens current school from new patients questionnaire Verify forms that express dissent to the: Summary Care Record dataset upload, Care Data Service and data to and from Health and Social Care to be used and code as required Obtain any past family medical history from records and code to computer appropriately Record any patient allergies identified appropriately Monitoring the progress of notes summarising against Umbrella Medical targets/deadlines Process and verify the GP to GP transfer of electronic and paper records for new patients to the practice, ensuring outstanding referrals and results are actioned appropriately Ensure that medications transferred via GP to GP are stopped and recorded and if needed a new patient medication review is booked by reception Verify that all records belong to the patient, and if not return to the appropriate organisation Post Reading Read electronic and hard copy of incoming correspondence; code or link diagnosis to record in patients problem page, code relevant investigations, and action requests as necessary Ensure relevant investigations necessary for a diagnosis such as MRI/ CT scan are recorded when coding problems such as TIA/Stroke/STEMIs Send tasks as relevant i.e. book appointment with doctor to reception Send reports/results as requested Check addresses are correct on clinic letters and notify reception if different to the address we hold to confirm with the patient and appropriate action can be taken Inform the practices Cancer Champion of a new diagnosis of cancer so the patient can receive the appropriate support Tidy up problem page/patient warning whenever possible by removing unnecessary or outdated information Ensure children subject a to child protection plan warning is removed when necessary by recording corresponding code when the child is no longer on register Add code/note to all other family members when a child is subject to a child protection plan or there is domestic abuse in household Code and monitor childrens DNA and vulnerable adults at hospital appointments, and inform the appropriate clinician/lead if necessary Auditing on an adhoc basis historical codes as required to ensure validity of coding Notify relevant summariser/lead on GSF if a patient is end of life so they can be put on the GSF register Any other duties considered by Umbrella Medical to be appropriate to the post