About this role
Job summary
The Clinical Coder and Summariser plays a vital role in maintaining accurate, high-quality patient records. The postholder is responsible for coding and summarising clinical information from patient records, hospital correspondence and other clinical documentation onto the Practice clinical system.
Working in line with Practice policies, NHS Digital guidance and information governance requirements, the role supports safe clinical care, accurate data reporting and effective population health management.
The role requires excellent communication skills, sound judgement, empathy, confidentiality and the ability to remain calm whilst managing competing priorities within a busy healthcare environment.
Main duties of the job
To support high-quality patient care by:
Ensuring accurate and timely coding of clinical information onto patient records Summarising patient records in a clear, concise and clinically meaningful format Supporting clinicians with accessible, well-structured patient histories Maintaining data quality standards in line with NHS and Practice requirements Contributing to improved patient outcomes through accurate record keeping and reporting
About us
Mortimer Medical Practice is a friendly, well-established GP practice located in the heart of rural Kingsland in Herefordshire, serving a diverse and supportive patient population. The practice has two branch sites in nearby Orleton and Leintwardine, all of which are dispensing. With nearly 9,000 patients, we are proud of our reputation for delivering high-quality, patient-centred care within a welcoming and inclusive environment.
Our multidisciplinary team works collaboratively and values mutual respect, professionalism and kindness. We foster a positive workplace culture where every team member is recognised for their contribution and encouraged to develop their skills and interests. Staff wellbeing is important to us, and we strive to maintain a supportive atmosphere where colleagues feel valued.
We are committed to continuous improvement, innovation and providing excellent clinical care. Our team benefits from strong clinical and managerial leadership, regular communication and opportunities for ongoing professional development. We encourage learning, share expertise across the practice and support career progression wherever possible.
As a group of smaller community-focused practices, we offer the opportunity to build meaningful relationships with patients and colleagues alike. We take pride in knowing our patients well and delivering personalised care that makes a real difference to their health and wellbeing.
Job description Job responsibilities
Principal Duties and Responsibilities
Clinical Coding
Extract relevant clinical information from hospital letters, discharge summaries and other correspondence Apply accurate clinical coding using SNOMED CT and other recognised coding systems Code diagnoses, procedures, medications, allergies and other relevant clinical data Ensure all coding is completed in a timely and accurate manner Identify and escalate any discrepancies or concerns within clinical documentation Summarising Patient Records
Review and summarise new patient records and existing records where required Produce concise and clinically relevant summaries of patient histories Ensure key information such as diagnoses, medications, allergies and significant past history is clearly recorded Maintain consistency and accuracy in summarisation standards Liaise with clinicians where clarification is required Data Quality and Information Governance
Maintain high standards of data accuracy and completeness within the clinical system Undertake regular data quality audits as directed Support the Practice in achieving QOF, IIF and other reporting requirements Ensure compliance with GDPR, NHS Confidentiality Code of Practice and Information Governance policies Maintain strict confidentiality at all times Administrative Responsibilities
Process incoming clinical correspondence via electronic workflow systems Manage coding-related tasks within EMIS Web or equivalent clinical systems Support document management processes and workflow allocation where required Liaise with clinicians and administrative staff regarding coding queries Team Working
Work collaboratively with clinicians, administrative staff and management Provide support and cover for colleagues during periods of absence Participate in Practice meetings and contribute to service improvement initiatives Demonstrate flexibility to meet the changing needs of the Practice Training and Personal Development
Participate in mandatory and statutory training Undertake ongoing training in clinical coding and summarisation Maintain up-to-date knowledge of SNOMED CT and NHS coding standards Participate in annual appraisal and personal development planning General Responsibilities
The duties outlined above are not exhaustive and may change in line with the needs of the Practice. The postholder is expected to undertake any reasonable duties appropriate to the role.
Health, Safety and Security
Maintain a safe and tidy working environment Adhere to all Health & Safety and Infection Prevention and Control policies Report hazards, incidents or risks promptly Follow Practice security procedures Confidentiality
The postholder will have access to sensitive patient information and must:
Maintain strict confidentiality at all times Only disclose information in accordance with Practice policies and legal requirements Handle all data securely and appropriately Equality and Diversity
The postholder will:
Act in a way that supports equality, diversity and inclusion Respect the dignity, needs and beliefs of patients and colleagues Promote a non-judgemental and inclusive working environment Quality
The postholder will:
Maintain high standards of work and accuracy Contribute to continuous improvement within the Practice Identify and report risks or issues relating to data quality or patient safety Communication
The postholder will:
Communicate effectively with clinicians and colleagues Respond appropriately to queries regarding coding and summarisation Recognise and adapt to different communication needs General Responsibilities
The duties outlined above are not exhaustive and may change to meet the evolving needs of the Practice. All employees are expected to undertake any reasonable duties consistent with the grade and nature of the post.
Place of Work:
The main place of work will be based at Leintwardine, but there may be times where travel is required to the practices branch surgeries at Orleton and Leintwardine.
Person Specification
Experience Essential
Experience of administrative work in a healthcare or office setting. Experience handling confidential information. High level of accuracy and attention to detail.
Desirable
Experience within NHS General Practice or Primary Care. Experience of clinical coding and summarising. Experience using EMIS Web or similar systems.
Qualifications Essential
GCSE (or equivalent) in English and Maths (Grade C/Level 4 or above)
Desirable
Clinical Coding qualification (e.g. AMSPAR or equivalent)
Knowledge Essential
Good understanding of confidentiality and data protection. Basic IT skills.
Desirable
Knowledge of SNOMED CT coding. Knowledge of EMIS WEB and DOCMAN. Understanding of QOF, IIF and NHS data requirements. Knowledge of medical terminology.
Skills and Attributes Essential
Excellent attention to detail. Ability to work accurately under pressure. Good organisational skills. Ability to prioritise workload.
Desirable
Analytical skills. Ability to interpret clinical information. Experience of data quality improvement.
Personal Qualities Essential
Reliable, methodical and conscientious. Professional and discreet. Team player. Ability to maintain confidentiality.
Desirable
Commitment to continuous improvement. Interest in data quality and healthcare outcomes.
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.
Employer details Employer name Mortimer Medical Practice
Address Leintwardine Surgery
High Street
Leintwardine
Shropshire
SY7 0LQ
United Kingdom
Employer's website https://www.mortimergpsurgery.co.uk/ (Opens in a new tab)