Health Records Clerk

Job overview

The Health Records Clerk is responsible for the accurate, complete and timely availability of patient records and documentation within the Electronic Document Management Systems as part of the patient clinical record.

The role involves being responsible for document retrieval, preparation, scanning, indexing and quality assurance processes in line with departmental procedures including the use of the EDMS, PAS and EMIS systems, along with a number of other systems and IT processes.

Main duties of the job

Working as a member of the Health Records Scanning Bureau, the post holder will be responsible for retrieval, transportation, archiving, preparation, indexing, scanning, sorting, handling and quality assurance of health records, supporting the digitisation of paper-based records into the Trust Electronic Document Management Systems (EDMS), Hyland Onbase and EMIS in line with departmental procedures.

The role is vital to support service users regarding health records related processes including medical staff, nursing staff, allied health professionals, medical secretaries, administrators and external agencies. Document preparation and manual scanning includes frequently being seated whilst completing these tasks.All post holders are to be involved in and adaptable to future changes in the scope and location of their role, supporting health records processes and being receptive to change as the Trust EPR and EDMS solutions develop and mature over time, in particular supporting processes that are compliant with BS10008 scanning standards.

Detailed job description and main responsibilities

Locate (using software such as CD View, Dip, Restore and PAS) request, obtain and make available case notes from main library and Off-Site Storage locations as required to be scanned into EDMS. Communicate with Apogee to arrange the return of critical care charts.

Receive, sort and send internal/external post forwarding to relevant team/ward as appropriate. This includes returning, tracking and ensuring the delivery of case notes to other trusts via post.

Liaise effectively with all disciplines of staff and other staff to ensure efficient lines of communication are maintained at all times.

Answer the telephone and deal with queries and requests in a prompt, pleasant and helpful manner, referring on, as necessary to the appropriate Team.

Participate and contribute to departmental meetings and feedback discussions.

Minimize hazards and report any identifiable hazards to Line Manager. Adhere to all safe systems of work applicable to the work area.

Report any information related incidents direct to the departmental manager immediately and ensure the Trust incident reporting process is followed.

Follow Trust and departmental processes and procedures to ensure a high quality, resource efficient and cost-effective service is provided.

Prepare documentation for scanning in line with departmental procedures, ensuring the records that are required are scanned into the EDMS, including utilisation of PAS to produce indexing barcodes.

Scan documentation using the departmental scanning devices and index records accordingly to ensure documentation is classified and indexed to the correct patient record.

Collect and transport paper records requiring scanning or archive from all areas of the organisation as required.

Undertake photocopying, filing or other administrative tasks when required.

Ensure that lifting and handling guidelines are adhered to and comply with all Health and Safety requirements. Carry out regular maintenance and cleansing of scanning devices to ensure devices are appropriately maintained and remain operational. Issues, faults or damages must be reported immediately.

Use trolleys safely in all areas of the hospital for the daily collection and transportation of health records from Wards and other departments.

Undertake any other duties required by manager appropriate to the Grade and relevant to the role, being flexible to the needs of the service to support effective delivery of service and support future changes of the health records service.

Governance & Quality

Maintain the health records department, documentation prepping and document sorting areas ensuring confidentiality, security, integrity and availability of health records at all times.

Ensure all requests for disclosure of information are directed to the Information Governance Team.

Ensure all movements of case notes are appropriately and accurately tracked on PAS.

Achieve a high standard of data quality when entering data into PAS or other departmental data capture processes e.g. activity logs, quality assurance logs.

Receive and sort loose paper filing in preparation to be filed within case notes or scanned into the EDMS, ensuring documentation is scanned to appropriate visit ID.

Maintain accurate and up to date records of work completed daily to ensure departmental KPIs and service level agreements can be monitored.

Undertake quality assurance processes to ensure documentation scanned into EDMS is indexed correctly and legible ensuring any deficiencies or issues are documented and rectified in a timely manner.

Champion and comply with the Records Management, Information Governance and Data Quality Policies.

Review the daily report from EDMS Scanning Tracking Location, and identify the correct process needed to ensure patients records are ordered/located.

Ensure compliance with manual handling including health and safety requirements to maintain sufficient space within the health records department including archiving of records and boxes to off-site storage.

Follow and comply with departmental procedure documentation. When new procedures are implemented or existing documentation updated, become familiar with the changes.

Applicant requirements

The postholder will have access to vulnerable people in the course of their normal duties and as such this post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service to check for any previous criminal convictions.