Summary
The role of the Trainee Clinical Coder is to analyse health and care terminology and other clinical information and assign and input 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 |
|---|---|
| Security and safeguards (Level Two) (BINT) | Assists in the application of appropriate safeguards and security procedures to the handling of data and any analysis results. |
| Sourcing and validation (Level Two) (BINT) Copy | Assists in the investigation of available information sources to establish what information is available and the reliability of such information. |
| Information requirements and search (Level 3)(BINT) | Determines what information is required and defines search and other criteria to meet a specified requirement. |
| Information handling (Level 2) | Maintains team filing and administration systems. |
| Records management (RMGT)(Level 2) | Performs administrative tasks to ensure accessibility, retrievability, integrity, security and protection of records. |
| Clinical coding audit (Level 2) (ANCC) | Supports and participates in feedback sessions regarding outcomes of clinical coding audits. |
| Clinical infomation(Level 2) (ANCC) | Extracts clinical information from the relevant patient record, 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 2) (ANCC) | Refers to ICD10/OPCS4 classifications in order to process accurately coded data. |
| Coding deadlines (Level 2) (ANCC) | Completes own workload within the agreed coding targets to achieve the required coding deadlines. |
| Coding quality (Level 2) (ANCC) | Liaises with all staff, both clinical and non-clinical, to clarify and resolve coding issues. |
| Coding standards (Level 2) (ANCC) | Works to learn and maintain up to date knowledge of all coding standards published by NHS England TCDS (Classifications Service). Works towards achieving the National Clinical Coding Qualification (UK). Is responsible for updating personal coding classifications following changes to standards published by NHS England TCDS (Classification Service). |
| Escalation (Level 2) (ANCC) | Raises coding issues with the more experienced clinical coding colleagues to ensure correct coding resolution is reached following the national coding query mechanism. |
| Quality assurance (Level 2) (ANCC) | Participates in quality assurance activities such as peer review or supervisor checks. |
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. |
| Customer Focus | Understanding the needs of the internal or external customer and keeping these in mind when taking actions or making decisions. |
| 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). | Familiar with |
| 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. | Familiar with |
| Function or Department Operations | The activities, structure, and position in the organisation of the functions or departments for which services are provided. | Aware of |
| 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. | Familiar with |
| 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. | 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 |
| Participation in Group Activities | Participating in group activities inside or outside of the working environment that can assist with the development of interpersonal skills. | Broadening Activities |
| Time Management | Undertaking learning and practice in the planning and organising of own activities. | Developing Professional Skills |
Qualification Components
| Title | Awarding Bodies |
|---|---|
| FEDIP Associate 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. | 1. Remember: Recall facts and basic concepts: define, duplicate, list, memorise, repeat, state. |
The Professional Body Responsible for this job family is IHRIM. This job role profile was created in collaboration with BCS, using Role Model Plus.