Follow an agreed protocol to summarise incoming patients Medical Records. Incoming paper records Read and process all hospital letters (discharge letters/outpatient reports, results etc), and transpose by coding any information onto the patient's clinical record. Code and "link" each "problem" appropriately as per the summarising protocol. Review and enrich the summary page.
Review QOF (Quality and Outcome Framework) performance markers and ensure read coding captures these codes. Identify gaps or errors in medical records and rectify as appropriate, or flag these gaps if unable to find any data. Record all allergies and sensitivities. Alert recall clerk to any potential recalls that need setting up/reviewing.
Ensure that information on safeguarding children (or vulnerable adults) is appropriately flagged and identified. Incoming electronic records - GP2GP Match electronic record on the computer. Validate all existing medical history (immunisations, problems, etc) entered by previous practice and complete any gaps. Tidy "home" page - removing old and out of date reminders, current and past medical history.
Check medication, allergies, and sensitivities in degraded GP2GP data. Record checking and verification Check medical record content for online coded record access (where patient has applied). Report findings back (via task) to usual GP. Check medical records (problems and summary items) for patients choosing to have enhanced summary care record.
Make any required amendments for accuracy. This job description is only a summary of what a Patient Administration Care Coordinator Medical Note Summariser job will entail. The role may expand and change over time as the needs of the PCN changes, the requirement of the Network Contract Directed Enhanced Service (DES) expands, or priorities of the population evolve. The Patient Administration Care Coordinator will also be expected to work effectively as part of a team to provide cover for other Care Coordinator roles when required.