Job summary

Responsibilities and day to day duties of the role:

• Assess patient records and notes content
• Identify and apply medical terminology terms into code
• Allocate diagnosis and procedural codes to patients records
• Extract information from all types of clinical documentation and assess relevant health record content
• Input clinical codes onto Patient Administration Systems
• Work under pressure to local financial deadlines
• Communicate with a wide range of stakeholders to gather and share information
• Undertake background research as necessary
• Identify data quality issues and take appropriate action

Main duties of the job

Analysing patient records and extracting and accurately recording all relevant clinical information to produce an accurate summary of the patients medical history

Checking and integrating medical records received electronically

Examining records and documentation for missing information

Assigning industry recognised codes

Ensuring that all QOF related data is captured

Maintain and improve a knowledge of anatomy, physiology and medical terminology

Use medical knowledge to correct mistakes found in existing patient records.

Collaborating with clinical colleagues and other healthcare professionals to ensure information accuracy

Ensuring that the practice complies with clinical coding guidelines

Ensuring that all clinical codes are current

Following practice protocols to ensure consistent and high-quality care is provided to our patients.

About us

Cotswold Medical Practice comprises of two surgeries, one at Moore Health Centre in Bourton in the Water and the other at Westwoods surgery in Northleach.