Medical Notes Summariser

NHS Jobs; Watford; On-site; GBP 21,000 - 27,000; Full time

Job summary

NHS Jobs in Watford is seeking a motivated records administrator to support primary care teams. You will review patient records from paper sources and GP2GP electronic transfers, accurately summarise histories, and code medical information to help clinicians deliver care.

You will maintain neat records, follow privacy and summarising protocols, observe confidentiality, and support staff with general admin tasks while upholding equality and diversity commitments in line with practice policies.

Responsibilities

• Review patient records from both paper sources and GP2GP electronic transfers.
• Accurately summarise and code relevant patient medical histories.
• Monitor summarising progress to ensure practice targets are achieved.
• File, store, and dispose of records in accordance with practice policies.
• Photocopy or prepare documentation as required.
• Maintain quality assurance in summarising by following the Bridgewater Surgeries Summarising Protocol.
• Record immunisations, allergies, and sensitivities accurately.
• Maintain records in a neat, tidy, and up-to-date condition, including correct labelling and repair where needed.
• Undertake general administrative tasks to support clinical staff when required.
• Dispose of duplicate or unnecessary documents in line with the shred all policy.

Job description

Key Responsibilities

• Review patient records from both paper sources and GP2GP electronic transfers.
• Accurately summarise and code relevant patient medical histories.
• Monitor summarising progress to ensure practice targets are achieved.
• File, store, and dispose of records in accordance with practice policies.
• Photocopy or prepare documentation as required.
• Maintain quality assurance in summarising by following the Bridgewater Surgeries Summarising Protocol.
• Record immunisations, allergies, and sensitivities accurately.
• Maintain records in a neat, tidy, and up-to-date condition, including correct labelling and repair where needed.
• Undertake general administrative tasks to support clinical staff when required.
• Dispose of duplicate or unnecessary documents in line with the shred all policy.

Confidentiality

In the course of seeking treatment patients entrust us with or allow us to gather sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.

Equality and diversity

The post holder will support the equality, diversity and rights of patients, carers and colleagues to include: Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies and current legislation Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings and rights.