Job description
JOB TITLE: MEDICAL NOTES/RECORDS SUMMARISER
REPORTS TO: Assistant Practice Manager
Job summary:
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 patient’s clinical records into the practice computer system, working strictly in accordance with the practice notes summarising protocol.
Main duties/key tasks:
1. Sorting patient records and letters in preparation for
2. Reviewing medical records and producing an accurate summary of the patient’s medical
3. Read coding the information into SystemOne
4. Auditing data collection standards in the
5. Monitoring progress of notes summarising against practice targets
6. Filing and retrieving paperwork
Confidentiality:
7. While seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately
8. 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
9. 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:
10. Using personal security systems within the workplace according to practice guidelines
11. Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks
12. Making effective use of training to update knowledge and skills
13. Using appropriate infection control procedures, maintaining work areas in a tidy and safe way free from hazards
14. Actively reporting health and safety hazards and infection hazards immediately when recognised
15. 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
16. Undertaking periodic infection control training (minimum annually)
17. Reporting potential risks identified
18. Demonstrate due regard for safeguarding and promoting the welfare of
Equality and diversity:
The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:
19. 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
20. Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues
21. Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and
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:
22. Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
23. 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:
24. Alert other team members to issues of quality and risk
25. Assess own performance and take accountability for own actions, either directly or under supervision
26. 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
27. Work effectively with individuals in other agencies to meet patients’ needs
28. Effectively manage own time, workload and resources
Communication:
The post-holder should recognise the importance of effective communication within the team and will strive to:
29. Communicate effectively with other team members
30. Communicate effectively with patients and carers
31. Recognise people’s needs for alternative methods of communication and respond accordingly
Contribution to the implementation of services:
The post-holder will:
32. Apply practice policies, standards and guidance
33. Discuss with other members of the team how the policies, standards and guidelines will affect own work
34. Participate in audit where appropriate
Values, behaviours and principles
We are always:
35. Compassionate – we show kindness, consideration and understanding in everything we do – and demonstrate our caring nature to our patient, people and communities
36. Accomplished – we are available day and night – a response, adaptable, professional NHS partner, providing the best advice, care and treatment for every individual
37. Respectful – we recognise the value that individual and team difference bring – welcoming views, listening, being honest, and learning from others’ experiences
38. Encouraging – we believe everyone matters, so we inspire confidence in other – promoting ‘speaking up’, fostering career-long learning and development, and supporting improvement ideas