Apprenticeship training course

Clinical coder (level 3)

Reading medical notes or records and analysing the contents which then translate into alphanumeric codes that accurately represent the patient’s stay.

• Qualification level: 3 ; Equivalent to A level.
• Typical duration: 18 months
• Apprenticeship category: Health and science
• Maximum funding: £5,000 ; Maximum amount government will fund ; for apprenticeship training.
• Skills:
  Skills an apprentice will learn

  • Assimilate and retain specialist information
  • Extract information for coding from a variety of sources both paper based and electronic
  • Consistently apply correct coding to a range of typical case notes and more complex scenarios
  • Follow the rules, conventions and standards for clinical coding as defined by NHS Digital Clinical Classifications Service and the World Health Organisation (WHO)
  • Consistently and correctly apply the four-step coding process as set on the NHS Digital website when assigning codes for diagnoses and procedures
  • Apply detailed knowledge of medical terminology, anatomical and physiological terms to translate the patients records into the correct codes
  • Follow locally defined coding rules where they have been agreed by the hospital, documented in the Clinical Coding Policy document and do not contravene the national rules defined by NHS Digital Terminology and Classifications Delivery Service module
  • Work with clinical teams and administrative staff to ensure that clinical codes are entered onto the correct Finished Consultant Episode (FCE)
  • Communicate effectively at all levels with a wide range of individuals, including clinicians, other hospital staff and colleagues
  • Relate appropriately with external agencies
  • Communicate complex clinical coding rules to relevant individuals
  • Ensure strict confidentiality when handling patient notes and information
  • Be involved in departmental internal audits
  • Ensure legal and information governance requirements
  • Extract information from all types of clinical documentation and assess relevant health record content
  • Correctly interpret data
  • Ensure every data entry is made in an accurate and timely manner against the correct patient’s record
  • Interrogate information and ask appropriate questions to resolve queries
  • Use the internet and systems to research background information regarding diagnostic and procedural statements and seeking advice from senior team members as necessary
  • Identify data quality issues and take appropriate action
  • Use different IT systems and applications for example: Patient Information Systems, Medicode, Excel, email and internet
  • Enter information accurately and correctly into information management systems
  • Work effectively with other departments within the organisation such as doctors, nurses, ward clerks, informatics
  • Follow organisational policies and procedures
  • Undertake organisational mandatory training as required

Full information on Clinical coder (level 3) is available from the Institute for Apprenticeships and Technical Education.

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