Patient record and coding services
Patient record and coding services staff provide timely access to information vital for patient care.
Life in patient records and coding services
You’ll be vital to ensuring patients receive safe, high-quality care by making sure accurate, complete and timely information is available whenever it’s needed. This includes bringing together the patient, their record, and the clinical team with the right information at the right moment.
Your work underpins the quality, safety and effectiveness of NHS services, whether you’re:
- analysing data in clinical audit
- translating clinical information into standardised codes in clinical coding
- managing and safeguarding patient records
Roles in patient record and coding services
Discover the career opportunties in patient record and coding services.
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You’ll work on projects which measure the effectiveness and safety of care for specific NHS services. You’ll then make recommendations on how care can be improved.
Your role may include:
- identifying audit topics based on national priorities such as NICE guidelines or local risks and setting measurable standards
- collecting data from patient records or surveys, ensuring it’s accurate and compliant with relevant legislation
- comparing current clinical practice against agreed benchmarks to identify gaps and presenting findings to multidisciplinary teams
- working with clinicians to develop action plans and recommendations for service improvement
- repeating the audit cycle to measure whether implemented recommendations have been maintained
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You’ll develop full and accurate digital records of a hospital activity including inpatient diagnoses and treatment. You will convert each patient’s diagnosis and treatment into code.
Your role may include:
- liaising with clinical professionals, including doctors, nurses and other staff to ensure that information is recorded accurately
- making a full and accurate computer record of hospital activity including outpatient appointments and inpatient stays
- reviewing data quality
- training staff in clinical coding
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Your knowledge of patient records, audit and coding will provide senior colleagues with expert advice and recommendations on managing records. You’ll make sure the organisation is keeping records in line with law and good practice.
You’ll also:
- ensure that there is a robust records management training programme in place
- be responsible for creating and managing policies relating to records management and data quality
- manage budgets
Michael Jones
Coded data and standards assurance audit specialist
Knowing the data we create plays an important part in improving patient care is the best bit of the job for me.
How much can I earn
You will be employed on a national pay and conditions system called Agenda for Change (AfC).
- Health records operative – Band 2
- Ward clerk – Band 2/3
- Inpatient/outpatient booking clerk – Band 3
- Clinical coder – band 4
- Health records team leader – Band 4
- Health records assistant manager – band 5 /6
- Senior clinical coder – band 5/6
- Service manager – band 7
- Patient services manager – band 8
How about the benefits
- the chance to make a difference to people’s lives
- flexible and parttime working options
- competitive salary progression
- ability to work across many sectors and locations
- excellent pension scheme
- good annual leave entitlement
- NHS discounts in shops, services and restaurants
Must have skills
Skills needed may differ depending on the role but generally you’ll need:
- strong interpersonal and communication skills
- critical thinking and problem-solving skills
- an ability to prioritise work to meet changing demands
- attention to detail and accuracy
- an understanding of technology, security and how data is accessed, managed and used in the NHS
- an ability to develop processes for the use of data
For more senior positions, you’ll also need:
- ability to deliver effective and accessible meetings and presentations
- strong leadership and managerial skills
- expertise in financial analysis and reporting
- experience in budget management
Entry requirements
You’ll need a minimum of five GCSEs with English and maths at Level 2 which is equivalent to GCSE Grade 4 or C or equivalent qualification such as functional skills.
- For clinical coding roles at bands 3 to 4 you may also need the Certificate of Technical Competence and for bands 4 and above, the National Clinical Coding Qualification
- For many band 5 roles such as health records assistant manager you’ll need a degree or equivalent experience in a relevant area
- For more senior bands, such as at band 8, you’ll need a Master’s or equivalent experience.
How to start your career in patient record and coding services
How to begin your career in clinical auditing
You might start by joining an apprenticeship programme and after gaining experience and skills, move onto more senior positions.
You could secure a post as a clinical audit assistant and with experience, professional development and training you could progress to more senior roles.
How to begin your career in clinical coding
You might be able to secure an entry level role with in-house training without previous clinical coding experience.
Or you might start by joining the level 3 Clinical coder apprenticeship programme and after gaining experience and skills, move onto more senior positions.
How to begin your career in records and information management
You might start in an entry level role such as a health records clerk and gain experience on the job. Alternatively, you could join an apprenticeship programme, for example data protection and information governance, and after gaining experience and skills, move onto more senior positions.
Where a career in patient records and coding services can take you
- There are training and development opportunities to help you progress to supervisory/senior management roles
- You may consider specialising in clinical coding or move into information governance
- For senior managers you could consider moving into general management in the NHS.
