Summary
The role of the Clinical Coder is to analyse health and care terminology and other clinical information and assign accurate diagnostic, intervention and procedure codes for all clinical data using the relevant coding classifications, namely ICD10 and OPCS-4, to enable the organisation to meet its business and clinical information requirements.
Work Activity Components
| Title | Details |
|---|---|
| Analysis (Level Three) (BINT) | Undertakes basic analytical activities, and assists with more complex activities, to deliver analysis outputs that conform to agreed standards. |
| Information requirements and search (Level 3)(BINT) | Determines what information is required and defines search and other criteria to meet a specified requirement. |
| Security and safeguards (Level Three) (BINT) | Applies appropriate security and quality safeguards to the handling of data, information, and any analysis results throughout the data lifecycle. |
| Sourcing and validation (Level Three) (BINT) | Investigates available information sources to establish what information is available. Assesses the integrity and reliability of data from identified sources. |
| Information Handling (RMGT)( Level 3) | Uses ethical and reliable methods to transform data between formats or media, following organisational policies and being aware of potential issues when handling information. |
| Records management (RMGT)(Level 3) | Conducts record collection, delivery and retention tasks ensuring ensure accessibility, retrievability, integrity, security and protection of records is maintained. |
| Advice and guidance (Level Three) (ANCC) | Provides advice and guidance on clinical coding to others. |
| Clinical coding audit(Level Three) (ANCC) | Supports and participates in feedback sessions regarding outcomes of clinical coding audits. |
| Clinical information (Level Three) (ANCC) | Extracts clinical information from relevant patient records, translates and assigns accurate diagnostic, intervention and procedure codes using ICD10/OPCS-4 classifications following and in-keeping with the national and local coding standards. |
| Coding accuracy (Level Three) (ANCC) | Refers to ICD10/OPCS4 classifications in order to process accurately coded data. |
| Coding deadlines (Level Three) (ANCC) | Completes own workload within the agreed coding targets to achieve the required coding deadlines. |
| Coding quality (Level Three) (ANCC) | Liaises with all staff, both clinical and non-clinical, to raise issues surrounding all aspects of the coding process and to clarify and resolve coding issues raised. Promotes clinical coding awareness and improvement by engaging with colleagues. |
| Coding standards (Level Three) (ANCC) | Works within and maintains up to date knowledge of all coding standards published by NHS England TCDS (Classifications Service). Is responsible for updating personal coding classifications following changes to standards published by the NHS England TCDS (Classification Service). |
| Escalation (Level Three) (ANCC) | Raises complex coding issues with the more experienced clinical coding colleagues to ensure correct coding resolution is reached following the national coding query mechanism. |
| Information interpretation(Level Three) (ANCC) | Uses judgement where necessary to translate cases where information is not always clear. Contacts clinical staff as necessary for clarification of information within source documentation where there is ambiguity. |
| Quality assurance (Level Three) (ANCC) | Participates in team quality improvement initiatives. |
Behavioural Skills
| Title | Details |
|---|---|
| Analytical Thinking | Acquiring a proper understanding of a problem or situation by breaking it down systematically into its component parts and identifying the relationships between these parts. Selecting the appropriate method/tool to resolve the problem and reflecting critically on the result, so that what is learnt is identified and assimilated. |
| Attention to Detail | Applying specific quality standards to all tasks undertaken to ensure that deliverables are accurate and complete. |
| Creativity | Taking innovative approaches to problem solving and/or devising inventive and creative solutions. |
| Customer Focus | Understanding the needs of the internal or external customer and keeping these in mind when taking actions or making decisions. |
| Initiative | Being proactive, anticipating opportunities for systems, service or product improvement or development and taking appropriate action(s). |
| Teamwork | Working collaboratively with others to achieve a common goal. |
| Verbal Expression | Communicating effectively using the spoken word. |
| Written Expression | Communicating effectively in writing, such as reports and via emails. |
Technical Skills
| Title | Details | Depth |
|---|---|---|
| Clinical Coding Auditing | Principles, practices, tools and techniques of clinical coding auditing. | Aware of |
| Clinical Coding Standards | The clinical coding standards used to assign codes to patient data (e.g. ICD10, OPCS-4). | Proficient in |
| Data Handling | The ability to harvest, clean, curate, manage, process and manipulate data in a variety of formats. | Aware of |
| Information and Data Visualisation/Presentation | The ability to visualise and present information and data in an appropriate format that helps stakeholders understand the significance of the information and data. | Aware of |
Other Skills
| Title | Details | Depth |
|---|---|---|
| Data Protection | Principles, practices, tools and techniques to ensure data protection. | Proficient in |
| Function or Department Operations | The activities, structure, and position in the organisation of the functions or departments for which services are provided. | Familiar with |
| Information Assurance Methods and Tools | Information assurance methods, tools and techniques (including the Caldicott Principles) used to protect the integrity, availability, authenticity, non-repudiation and confidentiality of user data and manage the risks related to the use, processing, storage, and transmission of information. | Proficient in |
| Information Elicitation Techniques | The selection and application of information elicitation methods, tools and techniques that are appropriate to the information required and the sources available. | Familiar with |
| Stakeholder Engagement | Establishing relationships, analysing perspectives and managing stakeholders from a variety of backgrounds and disciplines. Adapting stakeholder engagement style to meet the needs of different audiences. The identification of key business stakeholders and an assessment of their level of power and interests, and their perspectives to inform the way(s) in which they should be considered and managed. | Aware of |
Training
| Title | Details |
|---|---|
| Data Quality and Security | Methods and strategies used to ensure the quality and security of data. |
| Information Analysis | Tools and techniques which can be used to analyse and present data and to uncover latent information inherent in them. |
| Security Awareness | Tools and techniques to help users and employees understand the role they play in helping to combat information security breaches and for IT and security professionals to prevent and mitigate risk. |
Professional Development Activity (PDA)
| Title | Details | PDA Group |
|---|---|---|
| Communications | Undertaking learning and practice in oral and written communications, including report writing and presentation. | Developing Professional Skills |
| Gaining Knowledge of Employing Organisation | Gaining basic knowledge of the employing organisation, its business, structure, culture, policies, products/services, operations and terminology. | Increasing Knowledge |
| Gaining Knowledge of the Technical Environment | Gaining knowledge of IT activities in the employing organisation. | Increasing Knowledge |
| Involvement in Professional Body Activities | Attending meetings, seminars and workshops organised by professional body and reading published material, such as journals and web content. | Participation in Professional Activities |
| Job Shadowing and Special Assignments | Undertaking temporary periods or secondments in other roles, particularly those that offer a new perspective on own function or exposure to other environments and cultures. | Broadening Activities |
| Team Working | Undertaking learning and practice in the techniques of team and collaborative working. Gaining an understanding of the underlying concepts. | Developing Professional Skills |
Qualification Components
| Title | Awarding Bodies |
|---|---|
| FEDIP Practitioner | The Federation for Informatics Professionals |
| National Clinical Coding Qualification (UK) | Institute for Health Records and Information Management |
Clinical Informatics Framework
Information Systems & Technologies
| Title | Details | Level |
|---|---|---|
| Security and governance of data | Demonstrates knowledge of the security and governance of data, systems, devices and networks (e.g., Data Security and Protection Toolkit), and is able to use this to contribute to the development of solutions required to manage data. | 2. Understand: Explain ideas or concepts: classify, describe, discuss, explain, identify, recognise, report, select, translate. |
The Professional Body Responsible for this job family is IHRIM. This job role profile was created in collaboration with BCS, using Role Model Plus.