JOB DESCRIPTION

Job Title: Health Records Clerk

Band: 2

Base: QVH / Kings House, East Grinstead

Division / Department: Health Records

Hours: Full or Part Time

Reports to: Deputy Health Records Manager

Accountable to: Service Manager

Job Summary:

To analyse, process, collate, organise, retrieve and archive patient information for the purpose
of recording and informing on their care, the communication of their care between health
professionals and to meet legal, audit and governance requirements.

1 Working individually and as part of the departmental team, the health records clerk is
responsible for providing an efficient high quality support service to the Trust. Duties
must be carried out in strict accordance with departmental timescales guidelines and
policies. This includes both mental and physical effort. Tasks are carried out on a
rotational basis.

2 Main working relationships:

Internal and external groups of staff from any Healthcare provider

3 Budget responsibilities:
None

Trust: Queen Victoria Hospital NHS Foundation Trust

Care Group : Clinical Specialities Health Records

Service Manager

Deputy Health Records Manager

RTT18 Co-ordinators

Health Record Clerks

Updated: October 2012

_____________________________________________________________________

Key result areas:

Health Records Duties

Work within the departmental team and without direct supervision to achieve the following
duties on a rotational basis:

1. Initiate, retrieve and file casenotes and associated patient information.

2. Analyse, input and retrieve data from the Patient Administration System (PAS).

3. Ensure that all patient data is accurate, up-to-date and complete using electronic
tracing systems where necessary or by contacting relevant persons/agencies.

4. Identify through appropriate channels all inaccurate data and amend any information
that is incorrect or incomplete. This will include contacting patients to check
demographic details.

5. Be registered and issued with an NHS Smartcard, subsequently trained and adept in
the use of the NHS Summary Care Record (SCR) and Choose & Book (C&B)
systems in order to accurately trace record and amend patient demographics in all
areas of the job role and initiate patient care episodes.

6. Responsible for pulling and preparation of casenotes for weekly outpatient clinics and
admissions ensuring all clinics are completed by checking against weekly clinic rota.

7. Responsible for archiving, merging and destruction of casenotes according to Trust

policy using own judgement and knowledge in deciding appropriate course of action.

8. Maintain patient casenote and data quality where appropriate and in accordance with
departmental guidelines.

9. Carry out efficient, courteous and professional execution of queries by phone/email/in

person to the department from both internal and external sources.

10. Undertake ad hoc administrative duties as directed by the Deputy Health Records
Manager/Health Records Manager to enable the efficient running of the department.

11. Provide cover for colleagues within Health Records in times of sickness and annual
leave.

12. Be able to assist patients with their enquiries regarding surgical appliances when
appliance office is not manned.

Updated: October 2012

Referral Department Duties:

Processing and tracking all referrals for Plastic Surgery, Maxillofacial, Orthodontics & Oral
Surgery and General Hospital specialties. Referrals are received in both paper and electronic
format.

1. Analyse and process electronic referrals; each health records clerk is expected to be
able to download documents from their NHS.Net email accounts as well as the
departmental generic NHS.Net account/s.

2. To check current patient details against SCR and PAS record. Any updates or
amendments to be checked and recorded on both the manual and electronic record.

3. Undertake comprehensive Referral to Treatment in 18 Weeks (RTT18) training in

order to analyse, understand and apply accurate RTT18 patient pathway data to all
referrals that require it.

4. Undertake comprehensive C&B training in order to be able to understand and

process all C&B referrals on a daily basis. This includes checking against previous
C&B referral lists, ensuring complete demographic information is recorded, initiating
appointment and specialty data on PAS and paper referrals ensuring each is sent to
appropriate consultant/department for review.

5. Be able to identify and process all Two Week Wait (2WW) cancer referrals both from
GPs and tertiary locations; this includes identifying and recording the correct pathway
and ensuring information is sent to the appointments department in a timely fashion.

6. Accurately open an outpatient episode under the relevant consultant and/or medical
specialty for all appropriate referrals.

7. Registration of new patients on PAS according to hospital policy and administer

present departmental procedures in relation to this.

MANUAL HANDLING

Many aspects of the role involve lifting, sorting, filing and general handling of patient casenotes
and other documents as well as manoeuvring heavy trolleys loaded with patient casenotes on
at least a twice weekly basis.

Retrieval and filing of case notes from high/low shelving and the carrying of same.

Staff are regularly required to carry out duties in unfrequented archive library locations.

COMMUNICATIONS AND WORKING RELATIONSHIPS

Updated: October 2012

Efficient and courteous execution of queries to the department from both internal and external
sources.

Daily communication with staff of all levels, patients and agencies via telephone, email and
verbal/written.

All staff are expected to contribute to the decision making process related to the continued
development of quality standards and working practices in the department by way of active
participation in regular departmental and team meetings.

Updated: October 2012

 Person specification
Health Records Clerk

Area ESSENTIAL DESIRABLE

Qualifications
Good Secondary Education including ECDL
qualifications in English and Mathematics qualification
Customer Care related training/experience ITQ or
equivalent
experience

Experience
Clerical experience Experience of
Proven history of using a computer to input, working in an
analyse and process information as part of NHS
previous job roles/educational assignments administrative
Dealing with public/patients role

Knowledge
Filing systems Knowledge of
Keyboard skills health record
Basic knowledge of Microsoft packages filing systems
such as: Outlook, Word, Excel Confidentiality,
eg. DPA 98

Skills
Analytical Problem solving
Ability to work to tight deadlines under
pressure
Able to work as part of a team and alone
without direct supervision
Confident to raise issues and take on new
working practices when necessary
Prioritise workload on a daily basis
Ability to deal with documents that may hold
sensitive, unpleasant and emotional
material, both in text and image form e.g.
photographs of surgical wound sites and
procedures

Attributes
Self motivated
Flexible and adaptable
Friendly and hard working
Calm under pressure

Updated: October 2012

Additional
requirements Must be physically fit to be able to cope with
lifting, bending and manoeuvring of heavy
loads

Updated: October 2012