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.
2. 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.
3. 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.
4. 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.
5. To input Clinical Codes onto the Hospital Information Support System (HISS).
6. 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.
7. To deal with any queries or take messages for the staff within the Clinical Coding Department,
including Data Quality issues.
8. To bring to the attention of the Clinical Coding Supervisor any problems encountered or any
issues, affecting Clinical Coding.
Z: Data/Recruitment 2004/Clinical Coding/Clinical Coder (Grade 3)
05/02/2016
9. 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.
11. To provide clinical coding support during periods of sickness and annual leave to ensure the
Trust’s coding deadlines are met.
12. 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)
05/02/2016