About this role
Job summary
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.
Main duties of the job
Responsible for reviewing, summarising, and coding patient medical records from paper and electronic sources, ensuring accuracy and compliance with practice protocols. Maintains up-to-date, well-organised records, supports data quality and confidentiality standards, and provides general administrative support to the clinical team.
About us
Bridgewater Surgeries is a large teaching Practice based across 4 sites. Join our friendly team of clinicians and administrative staff. Benefits include 25 days paid leave plus bank holidays, nhs pension.
Job description
Job responsibilities
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.
Person Specification
Qualifications
Essential
- GCSE grade A to C in English and Maths
Experience
Essential
- Experienced Medical Notes Summariser
- Experience working in General Practice
Desirable
- SystmOne Experience
Employer details
Employer name
Bridgewater Surgeries
Address
Bridgewater House
7 Printers Avenue
Watford
Herts
WD18 7QR
United Kingdom
Employer's website
https://www.bridgewatersurgeries.nhs.uk/ (Opens in a new tab)