Heart of England NHS Foundation Trust

JOB DESCRIPTION

JOB TITLE: Clinical Coder

GRADE: Band 3

REPORTS TO: Clinical Coding & Data Quality Manager

RELATES TO: Clinical Coding Supervisor

Clinical Coding Staff

Data Quality Team

Medicine/Surgery Commercial Division Staff

Clinical Staff

Ward Managers

Ward Clerks

JOB SUMMARY:

To provide an efficient and high quality diagnostic and operative Clinical Coding Service, by collating & coding inpatient activity in line with International Classification of Diseases version 10 (ICD10) and Office of Population Census version 4 (OPCS 4) rules and regulations. To promote effective communication between the Clinical Coding Team and the clinical areas. To support and implement operational changes, to improve the quality of coding within the Trust.

KEY RESPONSIBILITIES:

  1. To acquire and maintain comprehensive knowledge and skills in the identification and application of medical terminology and anatomical and physiological terms for the efficient use of ICD10 & OPCS4 clinical coding.
  1. To allocate diagnosis and operative procedure codes to patient’s records on the Hospital Information Support System (HISS), in accordance with ICD10 and OPCS 4 standards.
  1. To extract clinical coding data, held at ward level, form a variety of sources. The primary source will be patients’ medical records, but other sources will include KMR1’ s and Trust systems such as Endoscribe, Clinical Letters and theatre transit forms.
  1. To locate missing data by whatever process necessary including contacting Medical Secretaries or by the pulling of case notes and requesting diagnoses and cause of death from the Coroners office where appropriate.
  1. To input Clinical Codes onto the Hospital Information Support System (HISS).
  1. To action daily outstanding clinical coding reports as required including, bringing them to the attention of the appropriate team members, and the Clinical Coding Supervisor when necessary.
  1. To deal with any queries or take messages for the staff within the Clinical Coding Department, including Data Quality issues.
  1. To bring to the attention of the Clinical Coding Supervisor any problems encountered or any issues, affecting Clinical Coding.
  1. To undertake training in order to maintain skills and to master new coding conventions as appropriate.

10. To develop coding and interpersonal skills by working closely with Clinicians and Ward staff to become an integral part of the team at ward level, to provide coding expertise.

  1. To provide clinical coding support during periods of sickness and annual leave to ensure the Trust’s coding deadlines are met.
  1. To identify and action Data quality issues as appropriate

GENERAL RESPONSIBILITIES

1.  To ensure the Trust’s policy on confidentiality, including patient information is maintained at all times.

2.  To communicate effectively with colleagues and to work as an efficient member of the team.

3.  Any other duties associated with the grade to ensure the smooth running of the department.

Z: Data/Recruitment 2004/Clinical Coding/Clinical Coder (Grade 3)

24/06/2008