Apprenticeship training course

Clinical coder (level 3)

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Information about Clinical coder (level 3)

Reading medical notes or records and analysing the contents which then translate into alphanumeric codes that accurately represent the patient’s stay.

• Knowledge, skills and behaviours:
  View knowledge, skills and behaviours

  Knowledge

  • Foundation knowledge of human anatomy, physiology and medical terminology
  • How to deconstruct and understand a medical term
  • An awareness of the role NHS digital and mandatory data set
  • How to apply codes to given diagnosis and treatments
  • The rules and conventions of the latest edition of international statistical classification of diseases and related health problems (ICD-10)
  • Relevant national standards and how to apply them
  • The need for accurate and high quality coded data to support healthcare planning, reimbursement, management of services, statistical analysis and research relevant to Clinical Coding
  • How to navigate through a medical record (paper-based and/or electronic)
  • The basics of Systemized Nomenclature of Medicine – Clinical Terms (SNOMED CT) its uses and benefits, how it complements the classifications and interacts with them
  • The purpose and function NHS Digital Delen specialist, collaborative and information sharing forum
  • Rules and requirements of Information Governance and how these impact on the work of the Clinical Coder
  • Different communication methods and how to adapt your communication to suit different audiences including senior clinicians for clarification when necessary
  • Data Protection and Security - The General Data Protection Regulation (GDPR) May 2018 and how it relates to your Clinical Coding role
  • The importance of maintaining confidentiality
  • The importance of information governance and the information governance toolkit
  • The impact of coding related data
  • The use of coding related statistics e.g. planning, identifying trends, analysing clinical outcomes
  • How data produced flows through and out of the organisation and the need to meet local and national deadlines
  • How coded data is used to satisfy many different purposes including Secondary Uses Service (SUS), Hospital Episode Statistics (HES), Hospital Mortality Indicators
  • How IT systems work and link to other systems within the organisation
  • How to access various systems within an organisation
  • How to navigate and use the NHS Digital Delen website
  • How to identify appropriate and reliable sources of information
  • How to use Display Screen Equipment safely
  • The healthcare environment and the different departments you are likely to work with
  • The purpose of the Clinical Coder’s role within the organisation
  • Where Clinical Coding sits in the wider environment
  • What it is like to work in a Clinical Coding office environment
  • Organisational policies and procedures; including the departments Standard Operating Procedure

  Skills

  • Assimilate and retain specialist information
  • Extract information for coding from a variety of sources both paper based and electronic
  • Consistently apply correct coding to a range of typical case notes and more complex scenarios
  • Follow the rules, conventions and standards for clinical coding as defined by NHS Digital Clinical Classifications Service and the World Health Organisation (WHO)
  • Consistently and correctly apply the four-step coding process as set on the NHS Digital website when assigning codes for diagnoses and procedures
  • Apply detailed knowledge of medical terminology, anatomical and physiological terms to translate the patients records into the correct codes
  • Follow locally defined coding rules where they have been agreed by the hospital, documented in the Clinical Coding Policy document and do not contravene the national rules defined by NHS Digital Terminology and Classifications Delivery Service module
  • Work with clinical teams and administrative staff to ensure that clinical codes are entered onto the correct Finished Consultant Episode (FCE)
  • Communicate effectively at all levels with a wide range of individuals, including clinicians, other hospital staff and colleagues
  • Relate appropriately with external agencies
  • Communicate complex clinical coding rules to relevant individuals
  • Ensure strict confidentiality when handling patient notes and information
  • Be involved in departmental internal audits
  • Ensure legal and information governance requirements
  • Extract information from all types of clinical documentation and assess relevant health record content
  • Correctly interpret data
  • Ensure every data entry is made in an accurate and timely manner against the correct patient’s record
  • Interrogate information and ask appropriate questions to resolve queries
  • Use the internet and systems to research background information regarding diagnostic and procedural statements and seeking advice from senior team members as necessary
  • Identify data quality issues and take appropriate action
  • Use different IT systems and applications for example: Patient Information Systems, Medicode, Excel, email and internet
  • Enter information accurately and correctly into information management systems
  • Work effectively with other departments within the organisation such as doctors, nurses, ward clerks, informatics
  • Follow organisational policies and procedures
  • Undertake organisational mandatory training as required

  Behaviours

  • Agile & Flexible – being tenacious and driven to see projects through to completion. A proven self-starter and have an adaptable approach to meet changing work priorities.
  • Professionalism & emotional intelligence – a high level of professionalism, reliable and dependable, collaborative approach and show empathy and being mindful of others
  • Has a desire to learn and a thirst for knowledge and a willingness to learn from mistakes
  • Shows emotional maturity – Ability to deal with direct exposure to disturbing photographs and case notes, potentially regarding abuse and terminally ill patients. There may be instances where you may be needed to attend a hospital ward where you may witness disturbing scenes
  • Adaptive to environment, working in both an office and busy healthcare environment
• Apprenticeship category (sector): Health and science
• Qualification level: 3; Equal to A level
• Course duration: 18 months
• Maximum funding: £5,000 ; Maximum government funding for ; apprenticeship training and assessment costs.
• Job titles include:
  • Clinical coder

View more information about Clinical coder (level 3) from the Institute for Apprenticeships and Technical Education.