Medical Summariser/Coder

Clinical Coding and Summarising Summarise newly registered patient records and records received from other healthcare organisations. Accurately extract and record relevant medical information into the patient record. Apply appropriate clinical codes using SNOMED and other approved coding systems in accordance with practice protocols. Ensure diagnoses, procedures, investigations, medications, allergies, immunisations and significant medical history are recorded accurately. Review patient records for completeness and identify discrepancies requiring clarification. Maintain accurate and clinically relevant problem titles within patient records. Ensure coded information supports effective clinical care, disease management and reporting. Assist with data cleansing and data quality improvement initiatives. Support the maintenance of practice registers and disease-specific databases. Identify and escalate concerns regarding clinical information where appropriate. Records Management Organise and maintain electronic patient records in accordance with practice procedures. Scan and attach documentation accurately to patient records. Process incoming correspondence and ensure appropriate filing within clinical systems. File, store and retrieve records as required. Maintain an organised and efficient workflow to ensure timely processing of documents. Audit and Quality Improvement Assist with data validation exercises and coding audits. Support the practice in achieving QOF and other contractual requirements through accurate coding. Participate in audits and quality improvement projects as directed. Review coding accuracy and contribute to continuous improvements in data quality. Support the development and implementation of coding policies, procedures and best practice guidance. Assist in preparing data for reporting and performance monitoring purposes. Administrative Support Provide administrative support to clinical and non-clinical teams when required. Photocopy, scan and process documentation as necessary. Support colleagues during periods of increased workload. Maintain effective working relationships with all members of the practice team. Undertake any other duties appropriate to the role as requested by management.