Swydd-ddisgrifiad a phrif gyfrifoldebau manwl

1. Communication

To attend seminars and training courses in order to receive and interpret clinical coding updates and effectively communicate these to all necessary staff.

Take part in departmental team meetings to discuss and agree local policy and coding convention variations as required, without contravening national standards to ensure consistency of coding across the Trust.

To act as lead contact with designated specialties and communicate complex issues with clinicians on coding queries relating to diagnoses and operative procedures in order to ensure accuracy and consistency of information.

Where applicable, attend clinical and management meetings to discuss complex coding rules and guidelines and answer questions with regard to coding, thus raising awareness of the importance of clinical coding.

2. Analytical and Planning

To abstract and analyse complex clinical information from patient records and translate this into a coded format in line with National Standards.

To code the specified number of episodes on a daily basis.

To be responsible on a day-to-day basis for the abstraction and analysis of complex and sensitive information from health records. This information often includes exposure to highly disturbing and upsetting details or photographs.

To have a high level of knowledge of Medical Terminology and Anatomy and Physiology.

3. Policy and Service Development

To assist in the organisation of the day-to-day running of the office and use initiative to prioritise own workload to ensure that coding is carried out in an accurate, timely and complete manner.

4. Financial and Physical Resources

Be aware of any problems in the office and report to appropriate manager or works department for remedial action.
Be aware of health and safety and incidents procedure.
Monitors stationery supplies as are necessary to complete tasks.

5. Staff Management

Act as mentor and assist in the education of less experienced coders.
To develop, in conjunction with the Clinical Coding Site Manager and Clinical Coding Deputy Site Manager, coding standards, and maintain on-going monitoring and audit procedures to ensure that coding is timely, complete, accurate and of a consistent high quality to meet the needs of the Trust.

6. Information Resources

Using national and international rules/conventions governing the use of the statistical classifications (ICD10 and OPCS4) as laid down by the World Health Organisation and connecting for health and comprehensive knowledge of anatomy, physiology and medical terminology, translate all diagnostic and procedural information relating to a patients care in hospital, including patient co-morbidities into coded data.

The post holder will work as part of a team of experienced trained and trainee staff and the job will involve rotation between duties working on all specialties.

Locate source documents, read and analyse histology and cytology reports. Access information from help sources i.e. internet coding websites, and other online medical information sites.

Manage and resolve enquiries relating to complex clinical information from all parts of the hospital received in the Department.

Ensure patient records are processed in the correct manner and paper records are tracked to appropriate destinations using the computer tracking system.

To ensure computer and paper records are passed for remedial action or processed in the correct manner.

Knowledge of specialised computer coding software, coding procedures and conventions.

Ensure compliance with relevant legislation and Trust policy in areas of Health and Safety, Confidentiality and Data Protection.