Job summary
This is an exciting opportunity to join our Medical Summarising team in an innovative, award winning CQC Outstanding Practice situated in East London.

The role involves reviewing incoming medical records, hospital correspondence, discharge summaries, clinic letters and other clinical documentation, identifying key diagnoses, treatments, investigations and relevant medical history. You will work closely with GPs and the wider practice team to ensure patient records are accurate, up to date and support safe, effective patient care.

Main duties of the job

• coding relevant patient data into the practice clinical system (EMIS Web)
• Sorting patient documents in preparation for summarising
• Reviewing medical records and producing and accurate summary of the patient's medical history
• Processing records using GP Links
• Monitoring the progress of notes summarised against practice targets
• Managing data quality issues
• Provide coding /summarising support and guidance to practice administrative and clinical staff
• Working flexibly to assist with gaps in administrative cover in regard of absences and extraordinary workload

About us
We have a strong ethos of teaching and training and you will be welcomed into our large Primary Care team of 16 Doctors, GPwSI in Dermatology/surgery, 4 Practice Nurses , 2 HCAs, Diabetic Nurse Specialist, 3 Pharmacists and 16,000 patients and you will instantly become a valued member of the team.

Every clinical and administrative member of staff is encouraged to develop professionally. The doctors are supported and encouraged to specialise, each has their own interest e.g. Substance Misuse, Mental Health, Dermatology, Minor surgery, Paediatrics and Womens health. Although a large organisation the whole team really is a happy family. We respect, listen to and value every member of staff, as each has an important role to play in the organisation.

Once a month, we have a whole Practice lunch where we can all get together. Educational meetings occur every week with lectures provided by in house or external speakers. We also have weekly clinical meetings to discuss hot topics, difficult cases and notices.

Job responsibilities
Key responsibilites

• 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.

Qualifications
Essential

• 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.

Desirable

• NVQ/QCF Level 2 or 3 in Business Administration, Health and Social Care, or a related subject.
• Previous NHS or primary care-related training.
• Knowledge or training in SNOMED CT, Read coding, EMIS or System One.

Experience
Essential

• Good understanding of medical terminology.
• Excellent attention to detail and accuracy.
• Good written and verbal communication skills.
• Strong organisational and time-management skills.
• Ability to work independently and manage workload effectively.
• Good IT skills and confidence using electronic clinical records.
• Understanding of confidentiality and the importance of protecting patient information.
• Ability to work as part of a multidisciplinary team.

Desirable

• Previous experience in an NHS, GP practice or other healthcare environment.
• Experience of reviewing and summarising medical records.
• Knowledge of clinical coding systems, such as Read Codes or SNOMED CT.
• Previous experience using primary care clinical systems such as EMIS or System One.

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.