JOB DESCRIPTION 1. JOB DETAILS Job Title: Responsible to: Medico - Legal Support Officer Team Supervisor Medico- Legal Department & Base: IM&T Health Information Management Team Number of Job Holders: 1 Job reference SS661 2 JOB PURPOSE To support the provision of a complete secure and efficient medical records service for Mental Health & Learning Disability Network, including the administration of Mental Health (Care and Treatment) (Scotland) Act 2003, and an accurate clinical coding service for mental health wards and community hospitals, and the administration of legal and personal requests for access to health records 3 ORGANISATIONAL POSITION Senior Health Information Manager Health Records Team Leader Team Supervisor Medico Legal Team Supervisor - Operational Senior Health/ Records Coordinators Medico Legal Support Appointments Co-ordinators Health Records Officers Page 1 of 6
4 SCOPE & RANGE Providing a focus on mental health services in particular the effective administration of the Mental Health Act legislation in respect of detentions, and co-ordinating the administration of medico-legal requests for casenotes [ +350 in 2007] a) Mental Health Records 22,560 (CRN same as BGH) b) Pre 1996-20,040 (Old Mental Health CRN) c) Provide advice and supervision re Mental Health Act to : 12 Mental Health Teams, 5 Mental Health Units, 14 Consultants, and 10 Mental Health Officers d) Mental Health Act Detentions during 2007/08 172 5 MAIN DUTIES /RESPONSIBILITIES a. Be a source of knowledge on the Mental Health (Care and Treatment) (Scotland) Act 2003 in order to accurately record Mental Health Act activity on epex) Notify clients and their relatives of detention in writing as required under Mental Health Act. Liaise with clinicians, social workers, the courts and the Mental Welfare Commission (MWC) for each section. Check review and expiry dates of sections and notify wards and consultants of these. Ensure that MHA forms are accurately completed by all parties and issued appropriately. b. Receive, record and process subject access requests for Health Records from patients and their representatives in accordance with the Data Protection Act 1998 and Access to Health Records Act 1990,ensuring that all relevant document have been provided. Raising an invoice and on receipt of fees, photocopy record or part of, record and dispatch relevant data to the requester securely ensuring that an audit trail is maintained. c. Retrieval/copying/production of health records data to authorised external agencies e.g. Benefits Agency, War Pensions Agency, Pneumoconiosis Panel, Private Patient Insurance Firms. d. Merge case records for patients with multiple unit numbers and case notes ensuring that the information merged is accurate. [Checks include Community Health Index number (CHI) contacting GP practices or GP etc to verify correct data] e. Run and distribute daily in-patient reports and statistics to relevant departments, action other reports as appropriate f. Amend and update PAS on notification of change of patient s details, date of death etc. g. Action general telephone enquiries both internal and external as appropriate. h. Record on epex, all Mental Health patient admissions and discharges, dates of authorised leave and day unit attendances, so that up to date information is available to clinical staff at all times on the system. i. Provide a clinical coding service for NHS Borders PACS Hospitals by completing diagnostic coding using ICD10 (International Statistical Classification of Diseases) for Scottish Morbidity Records and SMR01(GP beds) discharges, contacting community staff for relevant details. Contact Mental Health Teams to ensure the prompt return of SMR04 (Mental Health inpatient) coding details and key details on epex. j. To check and amend SMR00, 01 & 04 data to ensure compliance with Definitions & Codes before validating through ISD validation software (Clove) system, then electronically submitting by PCSMR to ISD. [This is required to be done each month to keep within national targets and deadlines, maintaining our accreditation level.] k. Demonstrate and explain practices and procedures to new staff. Page 2 of 6
6 SYSTEMS & EQUIP. 1. Patient Administration System (Trak) creation of patient records and records tracking 2. Community Health Index System (CHI) to search Scottish database for patient details and create new CHI numbers as required. 3. EPEX Community PAS 4. Quick Address System to identify post office addresses 5. MS Outlook email, for internal and external communication 6. Emergency Data Base used in the event of PAS not being on line 7. Internet and Intranet for research / intelligence 8. Printers (Report printer, label printer, outpatient letter printer including first level support to wards for label printers) 9. Fax machine and photocopier 7 DECISIONS & JUDGEMENTS 1 Uses own initiative to deal with enquiries, seeking advice from the Medico Legal Supervisor as appropriate 2 Uses own judgement when prioritising daily workload 3 Works to defined standards of COPPISH. Mental Health Act. Etc. 4 Work is generated by ward admissions and discharges and Mental Health Act detentions. Telephone calls and e-mails from Mental Health Teams requesting casenotes and informing of new clients to put on system. Courier delivery of returned casenotes to be filed. 5 Challenge assumptions made by others, and ensure correct decisions are made i.e. Highlight if believe errors on MHA forms re dates, time etc. 6 Advise clinical staff regarding coding issues, admin problems and mental health administrative procedures. 7 Use own judgement when sending weekly e-mail reminders to consultants and secretaries regarding imminent review, renewal and expiry dates for MHA 8 COMMUNICATION & RELATIONSHIPS Internal Supervisors/Clinic Co-ordinators Health Records Department staff Consultant Clinical Staff Nurse Managers Medical Secretaries General & Service Managers IM&T Department External Patients, Relatives and Visitors Central Legal Office, Police, Procurator Fiscals Office & Solicitors Mental Welfare Commission Scottish Tribunal Service General Practitioners and Practice Managers Scottish Ambulance Personnel Information & Statistics Division (ISD) 1. The post holder requires to have persuasive skills for example to influence clinicians when dealing with medico-legal issues. 2. The post holder requires to provide training and guidance to staff and other departments with regard to legislation affecting Health Records Services Page 3 of 6
3. Review of performance in the post is undertaken through the agreement of performance objectives and individual performance appraisal by the TS-ML. Formal appraisal is undertaken on an annual cycle. The TS-ML will give authority where necessary for the postholder to proceed with matters outwith their delegated authority or immediate roles and function. 4. Having a positive and friendly working relationship with colleagues, and management 9 PHYSICAL DEMANDS 1 High degree of accuracy required when entering demographic details of new patients on to CHI, TRAK and epex 2 Daily word processing of standard letters to detained patients and their relatives informing them of their rights. 3 Daily accurate data entry of admissions and discharges from Mental Health wards. 4 Daily accurate data entry of MHA details 5 Physical carrying and lifting of medical records for filing. 10 MOST CHALLENGING 1 Obtaining diagnostic coding information from community hospitals discharge letters are entered on epex by hospital staff to enable the post holder to access diagnostic details for coding. When this has not been done, information has to be requested from hospital secretary or ward staff, if no information is available at the hospital, the post holder will telephone the GP or access casenotes at the BGH in order to complete the clinical coding of the ward stay. 2 Processing MHA legislation Mental Health (Care and Treatment)(Scotland) Act 2003 paperwork. 3 Dealing with occasional confused and irritated patient /relative regarding a detention order 11 KNOWLEDGE, TRAINING & EXPERIENCE Knowledge of PAS and casenote procedures acquired either through experience, or qualification at NVQ Level 2 in an administrative subject. Knowledge of the Mental Health (Care & Treatment)(Scotland) Act 2003 /Adults with Incapacity Act. Sound understanding of medical records filing structures and library systems. Basic understanding of diagnostic coding (ICD 10 coding system) and broad understanding of NHS [ISD] Definitions & Codes Page 4 of 6
TERMS AND CONDITIONS Grade and salary: Band 2 14,508-17,253 per annum, pro rata Hours of work: 35 hours, fixed term until 30 June 2013 Annual leave: Public Holidays: 27 Days Details of other types of leave entitlement (such as sick leave) are set out in the Agenda for Change handbooks. 8 days per annum on dates designated by NHS Borders Details of other types of leave entitlement (such as sick leave) are set out in the Agenda for Change handbook. Superannuation: The post-holder is entitled to join the NHS superannuation pension scheme. If Unsuccessful: If you have NOT heard from us within 4 WEEKS of the closing date, then we regret that your application has not been successful on this occasion. However, we appreciate your interest in working with NHS Borders and your time and effort in completing the application form. We would welcome your application for future posts. Equal Opportunities: In NHS Borders, we believe that all staff should be treated equally in employment. We will not discriminate against any member of staff, or job applicant, on grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation. Trade Union membership. Disclosure checks: We carry out criminal record checks on new staff who fall within certain staff groups within NHS Borders, through Disclosure Scotland. We send out Disclosure Forms to all shortlisted candidates for these staff groups, and ask for these to be completed and returned at interview. If a successful-atinterview candidate forgets to bring their completed form to interview, then they will be required to return the form (and proofs of identity) within 7 days, otherwise the provisional job offer will be withdrawn. Unsuccessful candidates forms will be shredded. The Rehabilitation of Offenders Act does not apply to this post. Mandatory Induction Standards for Healthcare Support Workers in Scotland: Your performance must comply with the Mandatory Induction Standards for Healthcare Support Workers in Scotland and with the Code of Conduct for Healthcare Support Workers (in line with CEL 23 (2010)), both subject to amendment from time to time, which are attached. If, despite ongoing support, you fail to adhere to the Standards or to comply with the code, your performance will be managed in line with the NHS Borders Management of Employee Capability Policy and could result in the termination of your employment with NHS Borders. Page 5 of 6
Tobacco policy: We have a Tobacco policy in place. When selecting staff, we do not discriminate against applicant who smoke, but staff must observe our policy on smoking. Hepatitis B: We offer Hepatitis B immunisation through our Occupational Health Service (OHS). If you think you may be at risk of contracting Hepatitis B through your job, you should ask for this immunisation at OHS. If your work involves exposure-prone procedures, you must keep to the document Protecting Health Care Workers and Patients from Hepatitis B, and the NHSiS Management Executive Directive on this issue. You must be immune to Hepatitis B, and if you cannot prove that you are immune, OHS will investigate to find out whether you are Hepatitis B positive or not. Health and Safety at Work: You must take look after the health and safety of yourself and anyone else who may be affected by what you do at work. You must also co-operate with us to make sure that we keep to legal and organisational safety regulations. You can get more information from the NHS Borders Health & Safety Adviser. The closing date for completed application forms is: 5pm on Tuesday 5 March 2013 Page 6 of 6