Job summary
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.
Main duties of the job
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
Linden Hall Surgery has two sites, one in the Shropshire market town of Newport, and another in Muxton, Telford, with a combined list size of 15,500 patients.
The surgery consists of a close-knit team of 4 GP partners and 5 salaried GPs, alongside 4 Practice Nurses and 3 HCAs. We also have an expanding team of associate healthcare professionals including a First Contact Physiotherapist, a Clinical Pharmacist, Paramedics, Pharmacy Technicians, Social Prescribers, a Mental Health Practitioner, and an Age UK Link Worker. The clinical team is very ably supported by an extensive & experienced administrative team.
We are a total triage practice, with all patient contact coming through our online triage platform. All requests are reviewed by a GP who allocates the patient an appointment with an appropriate team member within a suitable timescale.
As a growing surgery our incoming workload continues to expand and it is vitally important for our patients that we continue to process and act on this accurately and efficiently.
Job description
Job responsibilities
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.
Job description
Job responsibilities
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.
Person Specification
Experience
Essential
- - Previous experience in a clinical coding or summarisation role.
- - Proficiency with electronic health record (EHR) systems (e.g., EMIS).
- - Knowledge of Read codes, SNOMED, or similar clinical coding systems.
- - Strong understanding of medical terminology.
- - Excellent attention to detail and organisational skills.
- - Ability to work independently and in collaboration with healthcare teams.
- - Understanding of confidentiality and data protection laws (GDPR).
Desirable
- - Certification in clinical coding or medical summarisation.
- - Previous experience in a primary care setting or GP surgery.
Person Specification
Experience
Essential
- - Previous experience in a clinical coding or summarisation role.
- - Proficiency with electronic health record (EHR) systems (e.g., EMIS).
- - Knowledge of Read codes, SNOMED, or similar clinical coding systems.
- - Strong understanding of medical terminology.
- - Excellent attention to detail and organisational skills.
- - Ability to work independently and in collaboration with healthcare teams.
- - Understanding of confidentiality and data protection laws (GDPR).
Desirable
- - Certification in clinical coding or medical summarisation.
- - Previous experience in a primary care setting or GP surgery.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.