SFIA Skills: Data and records operations

Understands and applies relevant classification/labelling systems, standards and guidelines.

Accurately assigns classifications/labels to low complexity information under supervision.

Uses established methods to transform records between formats or media, following organisational policies and procedures. Remains aware of potential issues when handling information.

Performs administrative tasks to ensure accessibility, retrievability, security and protection of records.

Produces reports in line with the organisation’s reporting needs.

Recognises when a query impacts on patient care and prioritises it accordingly.

Carries out routine configuration, installation and reconfiguration of database and related products ensuring information is accurate and of the highest quality. Understands the linkages between systems and identifies where associated systems also need to be updated. Deals with non-routine queries.

You are able to make use of appropriate information to help you analyse and correct a range of data quality problems some of which may be complex.

Ensures reports are produced in line with the organisation’s reporting needs.

Recognises when a query impacts on patient care and ensures the team prioritises it accordingly.

Manages database configuration(s) including installing and upgrading software, servers and application tools, ensuring information is accurate and of the highest quality. Understands the linkages between systems and identifies where associated systems also need to be updated. Deals with complex queries.

You are able to make use of appropriate information to help you analyse and correct a range of complex data quality problems.

Develops and implements the organisation’s clinical coding strategy.

Designs and oversees quality audit programmes.

Ensures that the necessary processes are in place and are operating effectively to ensure the resolution of coding issues in line with the national coding query mechanism. Provides the senior escalation point for the organisation.

Engages with industry bodies and partners to define and improve standards and working practices.

Leads quality assurance for the coding function and ensures coding standards are met. Supports and promotes the role of audit and training in embedding standards.

Leads the clinical coding function, ensuring that all deadlines are met.

Is accountable for the clinical coding auditing function. Leads the clinical coding management team to promote and implement improvements to address audit findings.

Contributes to organisational clinical coding strategy.

Develops and implements audit plans for assessing clinical coding accuracy and consistency. Analyses and reports on classification codes quality. Leads team quality audit programmes.

Ensures that the necessary processes are in place and are operating effectively to ensure the resolution of coding issues in line with the national coding query mechanism.

Collaborates with subject matter experts to improve source information quality.

Manages quality assurance for the coding function and ensures coding standards are met. Understands and supports the role of audit and training in embedding standards.

Manages the clinical coding function, ensuring that all deadlines are met.

May manage one or more clinical coding auditors, reports and makes recommendations based on their findings. Works as part of the clinical coding management team to promote and implement improvements to address audit findings.

Refers to ICD10/OPCS4 standards on a regular basis in order to process accurately coded data.

Leads clinical coding audits, reports and makes recommendations based on their findings. Works as part of the clinical coding management team to promote and implement improvements to address audit findings.

Performs quality assurance checks on the work of others. Investigates and corrects complex clinical coding errors.

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.

Resolves complex coding issues raised by less experienced clinical coding colleagues to ensure correct coding resolution is reached following the national coding query mechanism.

Demonstrates an understanding of best practice data policies, processes and standards, and implements them effectively. Understands which standards need to be applied where. Works effectively with subject matter experts to develop the rules, policies and guidance needed to safeguard the organisation’s data assets. Works within a team to monitor how data policies and standards are applied and complied with, taking action where necessary.

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).

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.

Ensures the team completes workloads within the agreed coding targets to achieve the required coding deadlines.

Refers to ICD10/OPCS4 classifications in order to process accurately coded data.

Manages a team of clinical coders to accurately extract clinical information from relevant patient records, translate and assign accurate diagnostic, intervention and procedure codes using ICD10/OPCS-4 classifications following and in-keeping with the national and local coding standards.

Supports and participates in feedback sessions regarding outcomes of clinical coding audits.

Provides advice and guidance to support and encourage adherence to clinical codng policies and standards.

Participates in team quality improvement initiatives.

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.

Raises complex coding issues with the more experienced clinical coding colleagues to ensure correct coding resolution is reached following the national coding query mechanism.

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).

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.

Completes own workload within the agreed coding targets to achieve the required coding deadlines.

Refers to ICD10/OPCS4 classifications in order to process accurately coded data.

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.

Supports and participates in feedback sessions regarding outcomes of clinical coding audits.

Provides advice and guidance on clinical coding to others.

Participates in quality assurance activities such as peer review or supervisor checks.

Raises coding issues with the more experienced clinical coding colleagues to ensure correct coding resolution is reached following the national coding query mechanism.

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).

Liaises with all staff, both clinical and non-clinical, to clarify and resolve coding issues.

Completes own workload within the agreed coding targets to achieve the required coding deadlines.

Refers to ICD10/OPCS4 classifications in order to process accurately coded data.

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.

Supports and participates in feedback sessions regarding outcomes of clinical coding audits.