Description
The Medical Notes Summariser is responsible for summarising and read-coding relevant clinical information into patients' electronic health records using SystmOne, ensuring accuracy, completeness, and adherence to the Bridgewater Summarising Protocol.
The role involves managing both paper and electronic records, maintaining high-quality data standards, and supporting the practice in meeting summarising targets.
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.
The post holder will support the equality, diversity and rights of patients, carers and colleagues.
Benefits include 25 days paid leave plus bank holidays, NHS pension.