Summarising Accurately summarise patient clinical records and enter these summaries into the electronic patient record in a timely manner, following current guidance and summarisation protocols. Input data into SystmOne clinical system with precision, ensuring that entries reflect the patients complete medical history, including vaccinations, allergies, and drug sensitivities, and that all information is correctly coded. Review incoming medical notes thoroughly, producing accurate and concise summaries of the patients history, and ensure any new or missing information is added to the clinical system after cross-checking for accuracy. Organise and tidy up the clinical tree by sorting patient data into relevant folders, presenting data in a clear, informative, and concise manner to facilitate quick and accurate access for clinicians. Proactively flag relevant information to the General Practitioner (GP) according to established protocols and use clinical knowledge to identify and escalate any anomalies or discrepancies in patient notes to the appropriate healthcare provider. Dispose of any non-essential information within the patient file in compliance with data protection and record management policies and maintain both electronic and paper-based medical records in an organised and secure manner. Sort and prepare patient records and incoming letters for summarisation, ensuring that all necessary documents are available and complete. Liaise with other healthcare providers and institutions to obtain any missing or incomplete information needed to maintain a comprehensive patient record. Regularly audit patient records for completeness and accuracy, identifying and rectifying any gaps or errors in accordance with practice protocols to support clinicians in accessing high-quality information efficiently. Scanning Diligently review and extract pertinent clinical information from both electronic and physical clinical letters received from various sources. Ensure that all relevant details are accurately captured to maintain the integrity of patient records and to support the continuity of care. Execute the scanning of relevant clinical data from both electronic and paper documents, ensuring smooth integration into patient electronic health records. Adhere to established scanning pathways and protocols. Verify the accuracy of all patient-identifiable information before scanning, safeguarding patient confidentiality and compliance with data protection regulations. Ensure that at least two forms of patient identification (e.g., NHS number and date of birth) are used when scanning and processing documents to ensure that all records are correctly attributed to the appropriate patient. Accurately enter and scan all forms of clinical correspondence, including letters, reports, and test results, into the organisations database. Ensure that documents are correctly filed within the appropriate patient record, following all relevant protocols and maintaining the organisation of the database. Vigilantly check all incoming correspondence for indicators of patients with emergency care plans. Promptly alert the relevant healthcare providers to ensure they are aware of any urgent care directives, enabling them to act accordingly. Collect incoming mail from the reception team, ensuring that all physical documents are promptly processed and integrated into the electronic records system. Prioritise the handling of urgent or sensitive documents to ensure timely updates to patient records. 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 may 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. 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 peoples 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, non-judgmental. 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: Completing all mandatory training on eLearning/Bluestream, ensuring that it is always up to date. 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 teams performance. Work effectively with other professionals / teams to meet patients needs. Effectively manage own time, workload and resources.