Assessor Resource

BSBMED401
Manage patient recordkeeping system

Assessment tool

Version 1.0
Issue Date: April 2024


This unit describes the skills and knowledge required to manage a patient recordkeeping system within a medical environment and to supervise others. It covers clarifying roles and responsibilities, managing the operation of a patient recordkeeping system, and reviewing and improving the system. The unit does not cover the design of a new system but does cover reviews and improvements to an existing system.

It applies to individuals managing an existing recordkeeping system (and sub-systems within the overall system) in a medical context. It may involve supervising the work of other personnel who implement the system and maintain patient records day-to-day. It also involves working with users of the system such as the health practitioners in the enterprise.

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. Clarify how patient records system operates

1.1 Access policies and procedures for patient records

1.2 Consult relevant personnel about how the system operates

1.3 Determine roles and responsibilities for the system operations

1.4 Communicate roles and responsibilities for system operations to relevant personnel

2. Manage operation of patient records system

2.1 Supervise staff maintaining patient records

2.2 Provide staff maintaining patient records with training as required

2.3 Regularly consult staff using patient records about system efficacy

2.4 Maintain integrity of patient records

2.5 Maintain security of patient records

2.6 Stress importance of confidentiality of patient records to all staff, who handle or have access to patient files

2.7 Provide authorisation of transfer of records from the workplace according to policies and procedures

2.8 Archive records as appropriate

3. Review and improve patient records system

3.1 Monitor and review implementation of the system to identify improvements

3.2 Make recommendations to relevant personnel for system improvements

3.3 Implement approved recommendations

3.4 Supervise staff maintaining patient records to implement changes

3.5 Plan and deliver any required training for staff to implement changes made to the system

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. Clarify how patient records system operates

1.1 Access policies and procedures for patient records

1.2 Consult relevant personnel about how the system operates

1.3 Determine roles and responsibilities for the system operations

1.4 Communicate roles and responsibilities for system operations to relevant personnel

2. Manage operation of patient records system

2.1 Supervise staff maintaining patient records

2.2 Provide staff maintaining patient records with training as required

2.3 Regularly consult staff using patient records about system efficacy

2.4 Maintain integrity of patient records

2.5 Maintain security of patient records

2.6 Stress importance of confidentiality of patient records to all staff, who handle or have access to patient files

2.7 Provide authorisation of transfer of records from the workplace according to policies and procedures

2.8 Archive records as appropriate

3. Review and improve patient records system

3.1 Monitor and review implementation of the system to identify improvements

3.2 Make recommendations to relevant personnel for system improvements

3.3 Implement approved recommendations

3.4 Supervise staff maintaining patient records to implement changes

3.5 Plan and deliver any required training for staff to implement changes made to the system

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
Access policies and procedures for patient records 
Consult relevant personnel about how the system operates 
Determine roles and responsibilities for the system operations 
Communicate roles and responsibilities for system operations to relevant personnel 
Supervise staff maintaining patient records 
Provide staff maintaining patient records with training as required 
Regularly consult staff using patient records about system efficacy 
Maintain integrity of patient records 
Maintain security of patient records 
Stress importance of confidentiality of patient records to all staff, who handle or have access to patient files 
Provide authorisation of transfer of records from the workplace according to policies and procedures 
Archive records as appropriate 
Monitor and review implementation of the system to identify improvements 
Make recommendations to relevant personnel for system improvements 
Implement approved recommendations 
Supervise staff maintaining patient records to implement changes 
Plan and deliver any required training for staff to implement changes made to the system 

Forms

Assessment Cover Sheet

BSBMED401 - Manage patient recordkeeping system
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

BSBMED401 - Manage patient recordkeeping system

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: