Health Records Clerk
Job Description & Person Specification –
A summary of the role responsibilities and person specification
Version Issued: December 2020
Why Our Trust?
Terms and conditions
Post – Permanent
Division – Trust Services
Department – Digital Services
Band – 2
Salary
Location – Bristol/Weston
Annual leave – Up to 33 days dependent on NHS Service
Pension - The NHS Pension Scheme is a defined benefit scheme. Further details and outline of
benefits can be found at: www.nhsbsa.nhs.uk/pensions
About us
Our mission is to improve the health of the people we serve by delivering exceptional care, teaching
and research every day.
What you’ll love about working here
UHBW has been rated by the CQC as ‘Good’ - our staff are proud to deliver excellent care. As a
forward-thinking multi-award winning Trust, our world-leading research and innovations are having a
positive local and global impact. Our hospitals are spread across Bristol and Weston-super-Mare, join
us and you can enjoy the very best of both worlds; city living within a stone’s throw of the countryside
or beside the seaside, both with easy access to all that the South West has to offer.
A digital exemplar - Being appointed as a Global Digital Exemplar means we can realise this vision by
implementing digital technologies that will help us to transform the way we work and how we relate to
our colleagues, patients and partner organizations.
Sustainable healthcare - We have joined the international movement to declare a climate emergency,
recognising the impact climate change is having on the world. Climate change is labelled as the
greatest threat to health in the 21st century, with a range of conditions related to heat, cold, extreme
weather and air pollution predicted to rise. To lead the way in healthcare the Trust has set ambitious
goals to become carbon neutral by 2030.
Access to further opportunities with the Trust - Apprenticeships are a great way to learn and earn
on the job. UH Bristol and Weston provides a range of apprenticeships to support a huge number of
career opportunities in clinical and non-clinical support services with apprenticeships starting at level 2
through to level 7. As an organisation we encourage further development of all employees to progress
upward within their chosen field.
Diversity & Inclusion
A core principle of the Trust is to ensure that patients and staff are treated with dignity and respect.
Promoting equality, diversity and human rights and challenging any form of inequality, discrimination,
harassment or abuse are central to the Trust’s Values. ‘Committed to inclusion in everything we do’ is
the ambition set out in the Trust’s Workforce Diversity & Inclusion Strategy.
Job Purpose
To ensure the patient notes are available where they are needed to support patient care. The
post holder will be responsible for retrieving case notes, which may be stored in the library or
other locations within the hospital/trust. Collating, organising, scanning and quality checking
case notes in readiness for future outpatient attendances and inpatient stays. The images will
then form part of the patients Electronic Patient Record
Health Records Clerk
Job Description & Person Specification –
A summary of the role responsibilities and person specification
Version Issued: December 2020
Main Duties and Responsibilities
To ensure the methodical pulling and organising of the patient’s case note records for
patient activity, this includes sending the patients case notes (both present & futures
processes) to out-patient clinics and to departments/wards for planned
admissions/emergency activity or directly to the scanning bureau in a timely manner
and in line with the Trust requirements.
Work as a team to prepare/maintain the patients case notes for the patient’s care
following manual and electronic processes at both the Medical Records Libraries and
within the Medical Records Scanning Bureau.
To investigate and track patients case notes i.e., searching the library for missing case
notes, searching & retrieving case notes for the emergency department and wards
from around the Trust. Ensuring that all case notes are updated on the Trust Medway
tracking system. Disclosure of patient information in accordance with current
legislation.
To work as a team to deal with loose filing/paperwork that comes into the current
Medical Records Libraries and within the Scanning Bureau.
The post holder will be required to provide basic advice and provisions regarding case
note retrieval and collections, or Access to Health Records, either face to face or using
the telephone to staff within the Trust, patients/visitors, other hospitals or with bona fide
outside agencies (e.g. benefit office, police etc.)
To follow the destruction policy and retention guidelines when the patient case notes
are to be destroyed and record destruction details on the Trust’s electronic tracking
system (Medway).
To ensure the methodical preparation and scanning of the patient’s case note records
using the Scanners is maintained to the highest standard, sharing best practice
between peers and managers. To be involved under guidance to carry out the first line
auditing process of scanned records on to the Electronic Document Management
system (EDM), checking quality of scanned documents, using own judgement to
decide when to delete and re-scan pages if necessary
Organisational Structure
Key Relationships
Trust Wide Operational Health Records & Scanning Bureau Manager, Assistant Health Records &
Scanning Bureau Manager, Senior Team Leader, Team Leader, Health Records Clerk Team
Health Records Team Leader
Health Records Clerk
Health Records Clerk
Job Description & Person Specification –
A summary of the role responsibilities and person specification
Version Issued: December 2020
To store and re-file the patient case note record within the Medical Records Libraries
using terminal or numerical numbering systems (some Medical Records Libraries use
both systems)
Under the guidance of your Team Leader or Assistant Medical Records Manager, the
post holder may be required to facilitate the processing of subject access requests,
recording the requests to ensure deadlines are met.
To ensure a prompt service provision is maintained across all working areas of the
Medical Records Departments & Scanning Bureaus in line with agreed key performance
indicators.
Attend and complete the Trusts mandatory training as instructed by Trust policy.
To undertake training and development and ensure adherence with any
policy/procedure/service level agreement or KPI identified by the line managers to
ensure professional practice is compliant. Targets/Goals will be set for the various
activities within the Medical Records for staff to adhere too.
Additional Requirements
There is a frequent requirement to exert light physical effort for several long periods during a shift
such as moving mobile racking, pushing trolleys, carrying loads some heavy lifting up to 6kg
standing at a photocopier, sitting for long periods at a computer workstation, and where it is
necessary team involvement in lifting boxes, pushing a cages, moving libraries (to create space).
Health Records Clerk
Job Description & Person Specification –
A summary of the role responsibilities and person specification
Version Issued: December 2020
Knowledge and Experience
KE1 Basic keyboard skills (E)
KE2 Understanding and maintaining of filing systems (E)
KE3 Working knowledge of Microsoft office i.e. Outlook, excel and word (E)
KE4 Working in a busy office environment (E)
KE5 Previous NHS Experience (D)
Aptitudes
A1 Have a pleasant manner and good communication skills (E)
A2 Accuracy & Numeracy (E)
Skills and Abilities
SA1 To have the physical ability to meet the very demanding requirements of the role (E)
SA2 Able to prioritise and manage own workload (E)
SA3 Be able to work fast and efficiently and in a safe manner (E)
SA4 Ability to work independently and in a team (E)
Qualifications and Training
QT1 NVQ Level 2 in Business Administration or equivalent (D)
QT2 Minimum of 2 GCSE’s which must include English and Mathematics (E)
Personal Profile - (E) = Essential (D) = Desirable
Health Records Clerk
Job Description & Person Specification –
A summary of the role responsibilities and person specification
Version Issued: December 2020
Safeguarding Children and Vulnerable Adults
The Trust is committed to safeguarding and promoting the welfare of all children, young people and vulnerable adults,
and as such expects all staff and volunteers to share this commitment.
Quality and Clinical Governance
Quality in the NHS has three core dimensions: Patient Safety, Patient Experience and Clinical Effectiveness. Clinical
Governance is about the systems, processes and behaviours to ensure that high quality services are provided to
patients. Every member of staff has a role to play in striving for excellence: it is important that everyone is aware of and
follows policies and procedures that govern their work; and if something goes wrong, everyone has an obligation to
report it so lessons can be learned from mistakes, incidents and complaints. If any member of staff has concerns on
any clinical governance matters, they should raise them with their line manager, professional adviser, or a more senior
member of management. Reference should be made to the Trust’s guidance on Raising Concerns about provision of
patient care.
Health and Safety
Under the provisions contained in the Health and Safety at Work Act 1974, it is the duty of every employee to:
Take reasonable care of themselves and for others at work
To co-operate with the Trust as far as is necessary to enable them to carry out their legal duty
Not to intentionally or recklessly interfere with anything provided including personal protective
equipment for Health and Safety or welfare at work.
Everyone has a responsibility for contributing to the reduction of infections.
Senior Management is responsible for the implementation throughout the Trust of suitable arrangements to ensure the
health, safety and welfare of all employees at work and the health and safety of other persons who may be affected by
their activities. Where health and safety matters cannot be resolved at Senior Management level the appropriate
Executive Director must be notified.
Line Managers are responsible for the health and safety management of all activities, areas and staff under their
control. This includes responsibility for ensuring risk assessments are completed and implementation of suitable and
sufficient control measures put in place. Health and safety issues are dealt with at the lowest level of management
practicable. Where health and safety matters cannot be resolved at a particular management level the appropriate
Senior Manager must be notified.
Transforming Care
Delivering sustainable healthcare services to our patients, which are effective, efficient and driven by excellence, is
at the heart of our organisation. Transforming Care is the Trust’s overarching programme of transformational
change. It enables staff to use a structured approach to continuously improve and innovates their services,
strengthen our capability, and deliver our Trust’s mission to improve the health of the people we serve by delivering
exceptional care, teaching and research, every day.
Our Quality Improvement Academy is open to all staff and leaders across the Trust, and provides training to lead or
take part in improvement and transformation activities in their departments and across the Trust. We will support
staff to develop the skills and tools to improve services to deliver the best care to our patients and public.
Information Governance
It is the responsibility of all staff to respect the confidentiality of patients and staff, as specified in the Caldicott
Principles, Data Protection Act 2018 and the Human Rights Act. It is the duty of every employee to:
Only access person identifiable information as required in the execution of their duties.
Disclose information appropriately, in line with the Data Protection Act 2018.
To ensure good quality data by recording, promptly and accurately, clinical and non-clinical
information within agreed timescales to PAS, the health record or the appropriate clinical or non-
clinical information system
Always trace patient notes on the Patient Administration System
Maintain the confidentiality of their passwords / usernames and if in possession of a ‘Smartcard’ abiding by the
terms and conditions of its use.
Workplace health and wellbeing
The Trust Workplace Health and Wellbeing Framework applies to all employees, students and volunteers who are
encouraged to take responsibility for their individual health and wellbeing and to promote the wellbeing of
colleagues. Line managers must recognise the importance of health and wellbeing and take it into account when
planning tasks and designing jobs.
