Medical Notes Summariser

Dr Laliwala and Partners; Peterborough; On-site; GBP 24,000 - 32,000; Full time

Job summary

Dr Laliwala and Partners in Peterborough is seeking an experienced Medical Notes Summariser for an initial 6-month fixed-term contract. The role involves reviewing patient records, summarising them on SystmOne, and coding with SNOMED CT to ensure accurate, accessible summaries for clinicians.

The successful candidate should have GP practice experience, meticulous attention to detail, and the ability to work independently while maintaining strict data protection and confidentiality in line with

Qualifications

• Experience in medical notes summarising within a GP practice.
• Strong attention to detail and accuracy.
• Good IT literacy and ability to use electronic clinical record systems.

Responsibilities

• Review and summarise incoming patient medical records onto the practice's clinical system (SystmOne).
• Identify and record relevant medical history, diagnoses, allergies, immunisations and significant clinical information.
• Enter information into SystmOne using SNOMED CT codes.
• Ensure summaries are accurate, complete and clearly structured.
• Prioritise workload to meet deadlines and maintain confidentiality.

Job description

Dr Laliwala and Partners are looking for an experienced and detail-oriented Medical Notes Summariser to join our friendly and supportive team in Peterborough on an initial 6-month fixed-term contract.

The successful candidate will be responsible for reviewing and accurately summarising patient medical records using SystmOne, ensuring that relevant clinical information is clearly documented and readily accessible to clinicians.

Previous experience of medical notes summarising within a GP practice is essential. We are looking for a reliable, organised and motivated individual who can work independently, maintain high standards of accuracy and contribute to the delivery of safe and effective patient care.

There may be an opportunity to extend the contract depending on operational requirements.

Main duties of the job

Main Duties and Responsibilities

Review and summarise incoming patient medical records, including paper records and electronic GP2GP transfers.

Identify and accurately record relevant medical history, diagnoses, surgical procedures, allergies, immunisations and other significant clinical information.

Enter relevant information into SystmOne using appropriate SNOMED CT codes in accordance with practice protocols.

Ensure medical summaries are accurate, complete and clearly structured.

Identify discrepancies, missing information or clinical concerns and escalate these to the appropriate clinician.

Manage and prioritise medical records summarising to meet agreed deadlines.

Maintain strict patient confidentiality and comply with data protection and information governance requirements.

About us

Dr Laliwala and Partners is an established primary care provider operating several GP practices across Peterborough.

We provide a wide range of NHS primary care services to a diverse patient population with varying healthcare needs. Our dedicated team of GPs, nurses, healthcare professionals and administrative staff work collaboratively to deliver high-quality, safe and patient-centred care.

We are committed to creating a friendly, supportive and inclusive working environment where staff are valued, encouraged to develop their skills and supported in their professional development. We continuously strive to improve our services, enhance patient experience and maintain high standards of care across our practices.

Job description

To accurately review, summarise and record relevant information from patients' medical records onto the practice's clinical system, SystmOne, ensuring that patient records are complete, up to date and readily accessible to clinicians.

The postholder will be responsible for maintaining high standards of accuracy, confidentiality and efficiency when summarising patient medical records.

• Review and summarise incoming patient medical records, including paper records and electronic GP2GP transfers.
• Identify and accurately record significant medical history, including diagnoses, long-term conditions, surgical procedures, allergies, immunisations and relevant family and social history.
• Accurately enter relevant information into SystmOne using appropriate SNOMED CT codes in accordance with practice summarising protocols.
• Ensure medical summaries are clear, accurate, appropriately structured and completed to a high standard.
• Review historical medical information and identify relevant clinical information that needs to be included in the patient's electronic medical record.
• Identify any missing, conflicting or potentially significant clinical information and escalation concerns to the appropriate clinician for review.
• Prioritise and manage the medical records summarising workload to ensure records are completed within agreed timescales.
• Maintain accurate records of completed summarising work and report progress to the Practice Manager as required.
• Follow practice policies and procedures relating to medical records management, confidentiality and information governance.
• Comply with UK GDPR, the Data Protection Act 2018 and NHS information governance requirements.
• Work independently while seeking appropriate clinical guidance where required.

Skills and Experience

The successful candidate will have previous experience of medical notes summarising within a GP practice, a good understanding of medical terminology and excellent attention to detail.

Experience using SystmOne and knowledge of SNOMED CT coding.

The postholder must be able to manage their workload efficiently, work accurately with minimal supervision and maintain strict patient confidentiality at all times.

Qualifications

• - Good standard of general education, including GCSE English and Mathematics at grade 4/C or above, or equivalent qualifications.
• - Good IT literacy and ability to use electronic clinical record systems.
• - Training in medical records summarising or clinical coding.
• - SystmOne training or relevant certification.
• Medical terminology qualification or relevant training.
• Relevant NVQ Level 2 or 3 in Business Administration, Healthcare Administration or equivalent.

Experience

• Previous experience of medical notes summarising within a GP practice.
• Good understanding of medical terminology.
• Excellent attention to detail and accuracy.
• Strong organisational and time management skills.
• Ability to work independently with minimal supervision.
• Good IT skills and understanding of patient confidentiality.
• Knowledge of SNOMED CT coding.
• Experience summarising GP2GP and paper medical records.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.