To accurately review, summarise and record relevant information from patients' medical records onto the practice's clinical system, SystmOne, ensuring that patient records are complete, up to date and readily accessible to clinicians. The postholder will be responsible for maintaining high standards of accuracy, confidentiality and efficiency when summarising patient medical records.

Main Duties and Responsibilities

Review and summarise incoming patient medical records, including paper records and electronic GP2GP transfers. Identify and accurately record significant medical history, including diagnoses, long-term conditions, surgical procedures, allergies, immunisations and relevant family and social history. Accurately enter relevant information into SystmOne using appropriate SNOMED CT codes in accordance with practice summarising protocols. Ensure medical summaries are transparent, accurate, appropriately structured and completed to a high standard. Review historical medical information and identify relevant clinical information that needs to be included in the patient's electronic medical record. Identify any missing,



conflicting or potentially significant clinical information and escal… Prioritise and manage the medical records summarising workload to ensure records are completed within agreed timescales. Maintain accurate records of completed summarising work and report progress to the Practice Manager as required. Follow practice policies and procedures relating to medical records management, confidentiality and information governance. Comply with UK GDPR, the Data Protection Act 2018 and NHS information governance requirements. Work independently while seeking appropriate clinical guidance where required.

Skills and Experience

The successful candidate will have previous experience of medical notes summarising within a GP practice, a good understanding of medical terminology and excellent attention to detail. Experience using SystmOne and knowledge of SNOMED CT coding. The postholder must be able to manage their workload efficiently, work accurately with minimal supervision and maintain strict patient confidentiality at all times.

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📌 Medical Notes Summariser (Peterborough)
🏢 NHS Jobs
📍 Peterborough