Medical Records Summariser

Job Summary

An exciting opportunity has arisen for a conscientious, organised, and detail‑focused Medical Records Summariser to join our Outstanding CQC‑rated GP Practice. You will be part of our Information Team, supporting the accurate and timely recording of clinical information for our patient population of over 35,000 patients.

This role is vital in ensuring the Practice maintains high‑quality, fully electronic patient records, supporting clinical decision‑making and patient safety.

Your key responsibilities will include extracting and summarising relevant clinical information from hospital correspondence and historical patient notes, and accurately inputting this information onto patients’ electronic medical records in line with strict practice protocols. You will be responsible for recording investigations such as x‑rays and scans, scanning clinical documents, and supporting wider data quality tasks. You will be expected to uphold patient confidentiality at all times and work collaboratively with colleagues to maintain high standards of data accuracy. 

 You must have:

• Excellent keyboard skills with experience of accurate and methodical data entry
• Previous experience in a Medical Records Summariser role
• Good attention to detail and the ability to follow protocols precisely
• Ability to manage your workload effectively and meet deadlines
• Awareness of the importance of confidentiality and information governance
• Ability to work as part of a team and communicate effectively with colleagues
• Knowledge of medical terminology (advantageous but not essential)

What we offer:

• NHS Pension Scheme.
• Generous annual leave (minimum pro-rata equivalent of 27 days, more if you have previous NHS service up to 33 days)
• Access to Westfield Health Scheme after successful probation period
• Free Parking

About us

Larwood Health Partnership is a GP Practice based over 4 sites. We believe in delivering a first-class service to our patients and are rated as Outstanding by CQC. Our patient list size continues to grow and as a result we are looking for a conscientious individual to help ensure the smooth running of the practice.

Job description

Job Purpose

To work as part of a team to input medical information, onto the patients’ computer records in accordance with a set protocol, which has been agreed by the Practice.

Other duties and responsibilities

• Attend practice meetings and any other meetings as requested.
• Undertake all mandatory training
• Follow security procedures
• Follow all Health & safety procedures

Special Considerations

• You may be required to work at any of our sites in Worksop, Carlton-in-Lindrick and Langold.  

Key Result Areas

• Extract all relevant medical information from the daily hospital letters and patients’ notes and input into the patient computer record following strict protocols to maintain a fully electronic patient record.
• Record all x-rays and scans received from the hospital onto the patients’ record to maintain a fully electronic patient record.
• May be required to carry out other related tasks including scanning of information onto patients’ records.
• Uphold confidentiality at all times.
• Support other staff in specific data quality tasks

Communications and Working relationships:

The post-holder should recognise the importance of effective communication within the team and will strive to:

• Communicate effectively with other team members
• Communicate effectively with patients and carers
• Recognise people’s needs for alternative methods of communication and respond accordingly

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.

In the performance of the duties outlined in this Job Description, the post-holder will have access to confidential information relating to patients and their carers, Practice staff and other healthcare workers. They may also have access to information relating to the Practice as a business organisation. All such information from any source is to be regarded as strictly confidential.

Information relating to patients, carers, colleagues, other healthcare workers or the business of the Practice may only be divulged to authorised persons in accordance with the Practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.

Health & Safety:

The post-holder will assist in promoting and maintaining their own and others’ health, safety and security as defined in the Practice Health & Safety Policy, to include:

• Using personal security systems within the workplace according to Practice guidelines
• Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks
• Making effective use of training to update knowledge and skills
• Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards
• Reporting potential risks identified
• All staff providing direct patient care must ensure that they follow procedures aimed at reducing the risk of passing on the organisms that can cause infections.  All staff, collectively and individually, have a duty of care in following best practice in adherence to guidelines which is a fundamental requirement in underpinning the management of Infection Control.

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 people’s 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-judgmental and respects their circumstances, feelings priorities and rights.

Personal/Professional Development:

The post-holder will participate in any training programme implemented by the Practice as part of this employment, such training to include:

• Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
• Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work

Quality:

The post-holder will strive to maintain quality within the Practice, and will:

• Alert other team members to issues of quality and risk
• Assess own performance and take accountability for own actions, either directly or under supervision
• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team’s performance
• Work effectively with individuals in other agencies to meet patients’ needs
• Effectively manage own time, workload, and resources