Clinical Coder

You will spend your time reading medical notes and records and analysing the contents which you will then translate into alphanumeric codes that accurately represent the patient's stay in hospital or the treatment they receive in Primary Care.

Clinical coders are responsible for making a full and accurate computer record of a patient's journey through care. You will translate diagnoses and treatment into alphanumeric codes. You will liaise with clinical professionals, including doctors, nurses and other staff to ensure that patients' diagnoses are recorded accurately. You will also be involved in reviewing data.

Clinical Coder is also known as Clinical Coding Officer, Diagnostic Coder, Medical Coder, or Nosologist.

Role Characteristics

Enter code and data into the clinical coding system
Scan patient information into computerised records, including medical documents, hospital records and letters
Forward clinical documents to clinicians following Trust or Practice protocols
Liaise with clinicians, medical and nursing staff and all other departments and directorates, to ensure that there is a constant awareness of the objectives and purpose of clinical coding
Check and review code data to ensure there are no errors or mistakes
Undertake a variety of administrative duties to assist in the smooth running of the Coding Team

Skills

Attention to detail
Decision-making
Following instructions
Communication
Record keeping
Using data

Day in the life

Watch this vide to learn about Clinical Coding.

Routes into this role

Here are some example routes that can lead into this role.

GCSEs

An apprenticeship

Apply directly

How to become

There are many routes into becoming a Clinical Coder and the entry requirements will depend on the role and what level it is. It is possible to start in an entry-level post without formal qualifications, but GSCEs or equivalent qualifications are an advantage.

You could undertake an apprenticeship in Health Informatics or Clinical Coding. Entry requirements for the apprenticeships will be down to the employer offering the apprenticeship.

More senior information management staff will likely have an undergraduate degree in Health Informatics while a postgraduate qualification in information and library work might be necessary for very senior roles. The NHS Graduate Management Training Scheme also has specialisms in Health Informatics and Health Analysis for graduates with relevant degrees.

It is important to check your preferred course provider's entry requirements for guidance.

Where can this role lead

No matter what role you start in or where you are in your career path, there are always opportunities to develop and progress in health and care.

With experience, you could become a Senior Clinical Coder or Department Manager. You could also move into a role supporting and teaching Clinical Coding. You could move into a more general Information Officer role and lead the delivery of information systems locally, regionally and nationally.