Assessor Resource

BSBMED303
Maintain patient records

Assessment tool

Version 1.0
Issue Date: May 2024


This unit describes the skills and knowledge required to maintain patient records within an existing medical records management system, under the supervision of a senior receptionist or practice manager.

It applies to individuals who apply a broad range of competencies in various medical administration contexts. They are skilled operators who are expected to exercise discretion and judgement in accessing and maintaining patient records while fully respecting patient privacy and the confidentiality of their details.

No licensing, legislative, regulatory or certification requirements apply to this unit at the time of publication.

You may want to include more information here about the target group and the purpose of the assessments (eg formative, summative, recognition)


Evidence Required

List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.

ELEMENT

PERFORMANCE CRITERIA

Elements describe the essential outcomes.

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Identify and clarify own role and procedures for patient recordkeeping

1.1 Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual

1.2 Access documented procedures for patient recordkeeping system and read for understanding

1.3 Seek clarification with relevant personnel of unclear or ambiguous procedures

2. Access patient records

2.1 Gain access to patient records to facilitate patient visit

2.2 Check currency and accuracy of patient demographic and personal details

2.3 Create new records according to enterprise protocols

2.4 Check records following patient visits, for practitioners’ instructions related to follow-up action

2.5 Store patient records according to organisational policy and procedures

3. Help maintain records

3.1 Make required checks of patient records

3.2 Carry out archiving of patient records as required

3.3 Transfer patient records to another health facility upon appropriate request for patient information

4. Monitor and review own role

4.1 Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices

4.2 Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records

Evidence of the ability to:

use a recordkeeping system to create, access, store and maintain accurate records, according to organisational and legislative requirements

identify and recommend improvements to recordkeeping system or own work practices

communicate with relevant people about patient records.

Note: if a specific volume or frequency is not stated, then evidence must be provided at least once.

To complete the unit requirements safely and effectively, the individual must:

outline relevant legislation, standards and/or codes of practice that affect patient recordkeeping

explain workplace policies and procedures related to patient recordkeeping, including privacy and confidentiality

describe the process used to set up and maintain a patient record

explain how coding systems help users to access and to maintain patient records.

Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the medical services administration field of work and include access to:

a recordkeeping system

documented procedures

case studies and, where possible, real situations

office equipment and resources.

Assessors of this unit must satisfy the requirements for assessors in applicable vocational education and training legislation, frameworks and/or standards.

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assingnment, checklist) and due date here

Assessment task 1: [title]      Due date:

(add new lines for each of the assessment tasks)

Assessment Tasks

Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.

ELEMENT

PERFORMANCE CRITERIA

Elements describe the essential outcomes.

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Identify and clarify own role and procedures for patient recordkeeping

1.1 Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual

1.2 Access documented procedures for patient recordkeeping system and read for understanding

1.3 Seek clarification with relevant personnel of unclear or ambiguous procedures

2. Access patient records

2.1 Gain access to patient records to facilitate patient visit

2.2 Check currency and accuracy of patient demographic and personal details

2.3 Create new records according to enterprise protocols

2.4 Check records following patient visits, for practitioners’ instructions related to follow-up action

2.5 Store patient records according to organisational policy and procedures

3. Help maintain records

3.1 Make required checks of patient records

3.2 Carry out archiving of patient records as required

3.3 Transfer patient records to another health facility upon appropriate request for patient information

4. Monitor and review own role

4.1 Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices

4.2 Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records

Evidence of the ability to:

use a recordkeeping system to create, access, store and maintain accurate records, according to organisational and legislative requirements

identify and recommend improvements to recordkeeping system or own work practices

communicate with relevant people about patient records.

Note: if a specific volume or frequency is not stated, then evidence must be provided at least once.

To complete the unit requirements safely and effectively, the individual must:

outline relevant legislation, standards and/or codes of practice that affect patient recordkeeping

explain workplace policies and procedures related to patient recordkeeping, including privacy and confidentiality

describe the process used to set up and maintain a patient record

explain how coding systems help users to access and to maintain patient records.

Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the medical services administration field of work and include access to:

a recordkeeping system

documented procedures

case studies and, where possible, real situations

office equipment and resources.

Assessors of this unit must satisfy the requirements for assessors in applicable vocational education and training legislation, frameworks and/or standards.
Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.

Observation Checklist

Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice Yes No Comments/feedback
Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual 
Access documented procedures for patient recordkeeping system and read for understanding 
Seek clarification with relevant personnel of unclear or ambiguous procedures 
Gain access to patient records to facilitate patient visit 
Check currency and accuracy of patient demographic and personal details 
Create new records according to enterprise protocols 
Check records following patient visits, for practitioners’ instructions related to follow-up action 
Store patient files following organisational policy and procedures 
Make checks of patient files 
Carry out archiving of patient files as required 
Transfer patient files to another health facility upon appropriate request for patient information 
Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices 
Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records 

Forms

Assessment Cover Sheet

BSBMED303 - Maintain patient records
Assessment task 1: [title]

Student name:

Student ID:

I declare that the assessment tasks submitted for this unit are my own work.

Student signature:

Result: Competent Not yet competent

Feedback to student

 

 

 

 

 

 

 

 

Assessor name:

Signature:

Date:

Assessment Record Sheet

BSBMED303 - Maintain patient records

Student name:

Student ID:

Assessment task 1: [title] Result: Competent Not yet competent

(add lines for each task)

Feedback to student:

 

 

 

 

 

 

 

 

Overall assessment result: Competent Not yet competent

Assessor name:

Signature:

Date:

Student signature:

Date: