Apprenticeship Standard

Clinical Coder Level 3

A Clinical Coder translates medical notes and records and translating them into alphanumeric codes representing information about the patient’s stay.

Clinical Coders work in NHS trusts or private hospitals. The data they record can be used to monitor and manage care, providing both clinical insight and information for hospital management.

Having some interest in and knowledge of biology or anatomy can be helpful.

Clinical Coders work as part of a team and provide support to senior colleagues. The team structure provides progression opportunities for those keen to build a career in clinical coding

Level 3

Advanced

Apprenticeship Duration

18 - 24 Months

Training method

Blend of online and classroom

Casestudy overlay
What to expect from Skills Training UK
  • Course content customized for your organisation and its goals.
  • Support from a dedicated trainer who will support with learning, skill competency and developing evidence for assessment.
  • Individual support and mentoring to make every apprenticeship a success.
  • Access to our virtual learning environment with virtual classes, on-demand videos and tasks to reinforce learning.
What does an employer need to do?
  • provide the learner with the opportunity to take part in work and projects which to produce a portfolio of evidence required for Apprenticeship assessment and completion.
  • Take part in progress reviews at regular intervals.
  • Have some involvement in the project(s) being undertaken.
  • Allow the apprentice an agreed amount of classroom time.

What is included in the Standard?

Knowledge

  • Foundation knowledge of anatomy, physiology and medical terminology
  • How to deconstruct medical terms
  • Applying codes to diagnosis and treatment
  • The role of data in healthcare planning, management and research
  • Navigating medical records
  • The basics of Systemised Nomenclature of Medicine – Clinical Terms (SNOMED CT)
  • Purpose, function and use of the NHS Digital Delen
  • Information Governance
  • NHS IT Systems
  • The healthcare environment
  • Organisational policies and procedures
  • Data flows

Skills

  • Assimiliate and retain specialist information
  • Communication at all levels
  • Consistently apply correct coding
  • Correctly handle patient information
  • Contribute to audits
  • Extract information from clinical documents
  • Correctly interpret data
  • Interrogate and analyse information
  • Identify and resolve data quality issues
  • Use a variety of IT systems
  • Accurately record information
  • Work effectively across departments
  • Identify reliable sources of information
  • Adhering to information governance
  • Navigating medical records

Behaviours

  • Agile and flexible – a self-starter with an adaptable approach to changing priorities.
  • Professionalism – reliable and dependable, shows empathy and is mindful of others
  • Thirst for knowledge and a willingness to learn from mistakes.
  • Emotional maturity – will encounter disturbing photographs and case notes, potentially regarding abuse and terminally ill patients.

Eligibility criteria

Individual employers will set their eligibility criteria. This might include Level 2 in English language, mathematics and a science subject.

Qualifications and professional recognition

Level 3 competency. Apprentices without level 2 English and maths will need to achieve this level before completing the end-point assessment.

End Point Assessment

To successfully complete the apprenticeship, the learner needs to pass an independent End Point Assessment which consists of two distinct assessment methods:

Assessment Method Area Assessed Weighting
Clinical Coding Test

  • Part A: Multiple Choice
  • Part B: Case Study Test
Knowledge and skills 50%
Professional Discussion Knowledge, skills and behaviours 50%

“Skills Training UK has been great. Their dedicated trainer-assessor has supported the learners at every step and provided the senior team with regular feedback – allowing us to monitor how the training has progressed and identify any areas that we felt needed greater focus.”

Joanna Fisher, Imperial College Healthcare NHS Trust

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