Medical Records Summariser/ Administrator

The practice is moving towards becoming a paper-light environment, and the main responsibilities of the post-holder will be to summarise and read code relevant information from the patients' clinical records into the practice computer system, working strictly in accordance with the practice notes summarising protocol.

Main duties/key tasks:

• Reviewing medical records and producing an accurate summary of the patients' medical history.
• Read coding the information accurately into the practice clinical system.
• Auditing data collection standards in the practice.
• Monitoring progress of notes summarising against practice targets.
• Filing and retrieving paperwork.
• Managing electronic summary care record data.
• Recording immunisation data and dealing with immunisation data requests.
• Dealing with documentation that arrives via the post/internally/externally and electronically.
• Scanning as required.
• Receiving medical records into the practice and storing and coding them appropriately.
• Faxing documents as required.
• Provide administrative support to the Safeguarding Lead, as part of a team of Safeguarding Administrators.
• To learn and use knowledge of how to code and summarise various safeguarding documents from different agencies, and to manage the list of patients and review these regularly.

This list is not exhaustive and may be subject to change in line with the needs of the organisation.

Confidentiality:

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately. In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential. Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.

Health & safety:

The post-holder will assist in promoting and maintaining their own and others' health, safety and security as defined in the practice Health & Safety Policy, the practice Health & Safety manual, and the practice Infection Control policy and published procedures. This will include:

• Using personal security systems within the workplace according to practice guidelines.
• Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks.
• Making effective use of training to update knowledge and skills.
• Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards.
• Actively reporting health and safety hazards and infection hazards immediately when recognised.
• Keeping own work areas and general/patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the job holder's role.
• Undertaking periodic infection control training (minimum annually).
• Reporting potential risks identified.

Equality and diversity:

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

• Acting in a way that recognizes the importance of people's rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation.
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
• Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings, priorities and rights.

Personal/Professional development:

The post-holder will participate in any training programme implemented by the practice as part of this employment, such training to include:

• Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.
• Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.

Quality:

The post-holder will strive to maintain quality within the practice, and will:

• Alert other team members to issues of quality and risk.
• Assess own performance and take accountability for own actions, either directly or under supervision.
• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team's performance.
• Work effectively with individuals in other agencies to meet patients' needs.
• Effectively manage own time, workload and resources.

Communication:

The post-holder should recognize the importance of effective communication within the team and will strive to:

• Communicate effectively with other team members.
• Communicate effectively with patients and carers.
• Recognize people's needs for alternative methods of communication and respond accordingly.