Detailed job description and main responsibilities

Retrieve and interpret clinical information from electronic patient record and other clinical source documents/systems, check data quality and record necessary amendments.

Term and encode clinical information in accordance with national guidance for clinical coding and classification systems and with local policies and procedures

Abstract and analyse patient clinical records, using judgement to obtain the correct diagnosis and operation in complex cases.

Apply clinical coding rules and conventions.

Liaise with clinical staff to ensure correct interpretation of clinical information

Promote clinical terming and coding standards within the clinical team and customer organisations.

Advise on the use of terms and codes required to analyse clinical data

Keep abreast of proposed changes and assist in the implementation of agreed local variations to coding rules.

To work on your own initiative, prioritising own workload on a daily basis, whilst maintaining an effective and efficient Clinical Coding service.

To critically examine and make independent judgements on whether coding should be carried out where diagnosis and procedural information is not transferable to exact codes or where a more detailed investigation is required for accurate coding.

Ensure data is accurately entered on the Patient Administration System via the Clinical Coding Software.

Provide support and specialist advice on coding issues to clinical staff and THIS customers as required.

Update the coding policy/procedures with changes advised by NHS England via the Data Quality journal.

Ensure continual self-development by keeping up to date with changes in coding practice and classification updates.

Adapt coding practice to incorporate new and additional codes released in the regular classification upgrades.

Participate in on-going clinical coding training to meet national standards and Trust requirements, including attendance on refresher courses and workshops. This may require travelling to other organisations outside of core working hours.

Keep up to date with changing clinical practice in relation to clinical coding.

Play an active part, within the team, to influence change in operational practice to achieve the overall aim of improving the quality of information.

Participate in the strategic development of the department including the resolution of local coding issues

To attend meetings at divisional / clinical level as and when required and liaise with Clinicians and Clinical staff for coding validation

Be aware of all the implications and adhere strictly to the Trusts confidentiality policy at all times with Electronic Patient Record/Case notes and patient information systems.

Be aware of Electronic Patient tracking/ tracing systems to facilitate completion of coded data and adherence to coding time constraints.

Be prepared to research new procedures both directly and indirectly using both the clinicians and the Internet which is vital in researching medical / surgical eponyms and procedural developments.

To maintain a thorough knowledge of Anatomy and Physiology, medical terminology, and abbreviations.

To gain a thorough knowledge of the Trust’s Clinical Information Systems in order to provide complete coding on patient care.

To take an active role in the identification and correction of data quality problems

To support the promotion of the professional image of the Clinical Coding service throughout the Trust.