The main responsibilities of the post-holder will be to scan documents, summarise and read code relevant information from the patients clinical records, hospital correspondence and other sources into the patients electronic SystmOne record held on the Practice Computer. Working strictly in accordance with the Practice notes summarising and read code protocols. Key Tasks Translate clinical information into appropriate read codes, forwarding letters onto GPs for checking. Summarise records and produce an accurate summary of patient medical history.
Record incoming & outgoing medical records onto SystmOne from Primary Care Support England. Liaise with Primary Care Support England with any queries relating to patient records and protocols. Extraction of necessary data from clinical correspondence and input into electronic patient record. View and disseminate hospital correspondence to GPs, ensuring that any urgent actions are flagged with appropriate member of staff.
Process links for pathology, radiology and microbiology results. Maintain efficient system to file historical paper medical records. Scan copies of relevant electronic and paper patient communications using SystmOne into patient records. Undertake GP2GP transactions for transfer of patient medical records.
Locate and retrieve documents as needed by clinical and non-clinical staff. Prepare monthly audit reports for clinicians when requested. Process tasks, emails and general queries. Deal with patient queries.