To abstract, analyse, translate and enter data for diagnostic and procedural codes, ensuring accuracy and completeness in accordance with national coding standards and local coding policies.
To access paper and electronic sources (the patient case note, plus electronic results and reporting systems), to determine the primary condition, all co-morbidities and all operative procedures applicable to each consultant episode of care to determine diagnosis and operative procedures.
To use coding reference books and electronic media as appropriate to allocate the ICD10 diagnostic codes and the OPCS4 operative procedure codes that most accurately describe the primary disease, co-morbidities and procedures as determined in no.1 above.
To enter the codes into the patient’s electronic record, observing and responding to any validation messages displayed by the computer system.
To locate, retrieve and return paper case notes as required from the wards, Medical Records department and Secretaries offices ensuring that all paper case notes are accurately tracked on the PAS system.
Warrington and Halton Teaching Hospitals NHS Foundation Trust is a caring and compassionate organisation that is both ambitious and innovative. We are committed to delivering the best outcomes for our patients and providing a positive experience of our staff. We aspire to be outstanding for our patients, our communities and our staff and are committed to being a great place to receive healthcare, work and learn.
Straddling the neighbouring boroughs of Warrington and Halton we are part of the Cheshire and Merseyside Integrated Care system. Our hospitals are ideally situated to meet the growing healthcare needs of the 330,000 population of these boroughs.
Warrington Hospital is home to our emergency, critical care and maternity services, Halton Hospital is focused on elective procedures and the Runcorn Urgent Treatment Centre, although many services are offered at both sites and in community hubs.
A CQC-rated ‘good’ organisation with ‘outstanding’ features, we are working towards university hospital status, having achieved teaching hospital status in 2019.
We employ nearly 5,000 people from over 80 nationalities, striving to be a diverse, inclusive employer and recognised leader in equality. We support flexible working, welcoming flexible applications. Proud of our many accreditations, we are embedding an anti-racist approach in all we do.
To keep up to date with national clinical coding standards and guidelines and to ensure adherence to local coding policies produced and maintained by the Clinical Coding Team Leaders and Manager. To undertake all coding tasks in accordance with these guidelines.
To be responsible for and to ensure all work allocated is completed to meet NHS deadlines and Trust targets, following up episodes where coding is incomplete on a weekly basis.
To ensure, as far as possible, that all records of deceased patients are accurately coded within the required deadlines.
If, during the coding process, any discrepancy is noticed between local coding or data collection processes and national guidelines, to make the Clinical Coding Team Leader and Manager aware of this so that the local coding policy document can be updated.

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