Medical Notes Summariser (Park Leys)

Role Summary To accurately review, summarise and input clinical information from patient medical records, ensuring that notes are clear, concise and accessible to support effective patient care and clinical decision-making.

Key Responsibilities

• Review and summarise patient medical notes, including clinical letters, test results and hospital discharge summaries.
• Review and clean up patient medical records by ensuring that the problem list is accurate and up to date, removing duplicate or irrelevant entries and streamlining notes to improve clarity and usability for clinicians.
• Ensure that only relevant and active clinical problems appear on the problem list, supporting effective patient care and decision-making.
• Ensure summaries are accurate, clear and compliant with clinical and data governance standards.
• Assist with backlog clearance and ongoing summarisation tasks to support clinicians and improve record quality.
• Add bulk childhood immunisations and seasonal vaccines onto the clinical system.
• Undertake audits of work to ensure compliance and support quality improvement projects.
• Identify and promptly flag any discrepancies, safeguarding concerns or urgent clinical issues to the appropriate member of staff.
• Manage patient medical records received for summarising, ensuring they are processed and tracked appropriately and, once completed, filed or retained within the practice or returned/transferred to the appropriate organisation as required.

General Administration

• Attend meetings as required.
• Attend relevant training sessions.
• Keep up to date with all statutory and mandatory training.
• Maintain confidentiality at all times.
• Work in line with all practice policies and standard operating procedures.
• Complete any other reasonable management instruction.