Job Description

Job Overview

We are seeking a detail-oriented and organised Medical Summariser to join our healthcare data management team. The successful candidate will be responsible for accurately summarising medical records and clinical data, ensuring clarity and compliance with organisational standards. This role offers an excellent opportunity for individuals with strong analytical and communication skills to contribute to vital healthcare processes in a professional environment.

Core Activities in Summarising Patient Records

1. Sources of Records

Paper Lloyd George records

via PCSE courier (Wednesdays).

Electronic records

via GP2GP transfer.

2. What to Summarise

Active Conditions

: Current or lifelong conditions.

Past Conditions

: Surgeries, mental health issues, or other resolved but relevant events.

Childhood Illnesses

: Chickenpox, measles, etc.

Vaccinations & Immunisations

Allergies

: From records or patient registration forms.

Female History

: Pregnancies, terminations, miscarriages, smear history.

Military Veterans

: Record status and related conditions due to service.

3. Coding

Use appropriate clinical codes to record conditions and events in EMIS.

4. Administrative Checks

Ensure reviews are not overdue. Acknowledge receipt of new records (paper or electronic). Deduct patients as instructed by PCSE. Handle GP2GP requests from other practices.

Handling Transfers and Deductions

Request deductions

for deceased, emigrated, or recoused patients to reduce "ghost patients".

GP2GP transfers

only work within England. Transfers from/to other UK countries require full printouts and manual record creation. Delays may occur; summaries may need to be requested manually.

Digitisation & Archiving

Prepare and pack Lloyd George and A4 records for digitisation. Records are scanned and uploaded to EMIS; originals are destroyed.

Research & Support

Respond to GP and secretary requests for specific medical history. Assist with referrals and condition management.

Adoption Process

Original records are redacted and archived. New identity and NHS number created. Redacted records scanned into the new record with

no reference to previous identity

.

Acknowledging Patient Records

Electronic Records (GP2GP):

Confirm receipt of GP2GP transfers from other practices. Action the request by integrating the data into EMIS. If records are incomplete or missing, note the limitation and proceed with available information.

Paper Records (Lloyd George):

Acknowledge receipt via PCSE courier (usually Wednesdays). Check for completeness and begin summarisation. Prepare for digitisation if applicable.

Deducting Patient Records

Instructions from PCSE:

Follow weekly labels received for patients to be deducted. Dispatch records accordingly for collection.

Types of Deductions:

Deceased (DOA) patients

Emigrated patients

Recoused patients

(those who have moved or are no longer under care)

Purpose:

Reduce the number of "ghost patients" in the system. Maintain accurate and up-to-date patient lists.

Process:

Request deductions via appropriate PCSE channels. Ensure records are securely packed and labelled. Confirm collection by courier or electronic transfer.

Researching Patient Medical History

1. Purpose of Requests

Support

referrals

to specialists or services. Assist in

managing chronic or complex conditions

. Provide background for

clinical decision-making

.

2. Sources of Information

Lloyd George paper records

(if not yet digitised).

EMIS electronic record

(coded and summarised data).

GP2GP transferred records

.

New registration forms

(for allergies, female history, etc.).

3. What to Look For

Specific diagnoses or historical conditions. Past treatments, surgeries, or hospital admissions. Mental health history. Immunisation and allergy records. Female health history (e.g., pregnancies, smear tests). Military service-related conditions (for veterans). Any redacted or archived records (e.g., adoption cases).

4. How to Respond

Locate and extract relevant information. Summarise findings clearly and concisely. Provide printouts or digital summaries to the requesting GP or secretary. Ensure confidentiality and data protection compliance.

Best Practices

Use

clinical coding

to ensure consistency. Flag

missing or incomplete records

and note limitations. Maintain a log of requests and responses for audit purposes. Collaborate with secretaries and clinicians to clarify unclear requests.

Recording Military Veterans in Patient Records

1. Identification

Patients who have served in the armed forces should be

flagged as Military Veterans

in their EMIS record. This status may be declared during registration or discovered during consultations or record reviews.

2. Why It Matters

Medical conditions may be

caused or worsened

by military service. Veterans may be eligible for

specialist services

, support, or prioritised care. There is a

directive

requiring this information to be recorded.

3. How to Record

Use appropriate

clinical coding

to mark the patient as a veteran. Note any service-related conditions or history in the summary. Ensure visibility for clinicians during consultations.

4. Supporting Tasks

Respond to GP or secretary requests for veteran-related history. Include relevant details in referrals or care planning. Maintain confidentiality and sensitivity around service history.
Job Type: Part-time

Pay: 12.21 per hour

Expected hours: 24 per week

Benefits:

Company pension On-site parking
Work Location: In person