Clinical Coder & Medical Records Summariser

Woodgrange Medical Practice; Greater London; Sur place; GBP 22 000 - 32 000; Plein temps

Résumé du poste

Woodgrange Medical Practice in East London invites applications for a Medical Summariser to join our team. You will review incoming medical records, hospital correspondence and discharge summaries to identify key diagnoses, treatments and medical history, ensuring accurate, up-to-date patient records to support safe patient care.

You will work closely with GPs and the practice team, coding data into EMIS Web, sorting documents, and producing concise summaries while maintaining confidentiality

Qualifications

• GCSEs or equivalent including English and Mathematics.
• Qualification or training in medical terminology, medical administration or clinical coding.
• Evidence of good IT and administrative skills.
• Ability to accurately interpret and record information from medical documentation.

Responsabilités

• Review new patient medical records and summarise relevant past medical history.
• Read and process hospital letters, discharge summaries, outpatient correspondence, investigation results and other clinical documentation.
• Identify and accurately record diagnoses, procedures, medications, allergies, significant medical history and other relevant clinical information.
• Apply appropriate clinical codes in accordance with practice procedures and established coding standards.
• Ensure patient records are maintained accurately and consistently.
• Identify missing, unclear or potentially significant information and refer appropriately to the relevant clinician or practice team member.
• Process incoming clinical correspondence within agreed timescales.
• Maintain strict patient confidentiality and comply with GDPR, NHS information governance and practice policies.
• Follow practice procedures relating to safeguarding, data protection, information security and patient safety.
• Liaise with GPs, nurses, administrative staff and other members of the multidisciplinary team when clarification or further action is required.
• Maintain a high level of accuracy while working to agreed deadlines and workload requirements.
• Undertake any other appropriate duties relevant to the role and level of responsibility.

Connaissances

Medical terminology

Attention to detail

Organisational skills

IT skills

Confidentiality

Formation

GCSEs including English and Maths

Medical terminology / medical administration training

Outils

EMIS Web

GP Links

SNOMED CT

Read Codes

Description du poste

Woodgrange Medical Practice in East London invites applications for a Medical Summariser to join our team. You will review incoming medical records, hospital correspondence and discharge summaries to identify key diagnoses, treatments and medical history, ensuring accurate, up-to-date patient records to support safe patient care.

You will work closely with GPs and the practice team, coding data into EMIS Web, sorting documents, and producing concise summaries while maintaining confidentiality