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 define the essential outcomes | Performance criteria describe the performance needed to demonstrate achievement of the element. |
1. Identify and evaluate clinical data from simple medical records | 1.1 Identify the principal diagnosis and principal procedure for an admission when coding from a simple medical record 1.2 Identify additional diagnosis and procedures when coding from a simple medical record with specialties 1.3 Refer any issues concerning clarity and accuracy of the clinical data to the appropriate person 1.4 Evaluate the relevance of other health conditions and factors affecting the patient to establish the principal diagnosis 1.5. Establish the appropriate level of detail of clinical data to meet standards 1.6 Record, enter, edit and maintain a client information system of coded data (disease index) 1.7 Identify the correct clinical data within appropriate timeframes |
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2. Assign codes to clinical data | 2.1 Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease and procedures codesabstracted from simple medical records 2.2 Apply Australian coding standards (ACS) where appropriate, to ensure the correct assignment of codes when coding simple medical records for specialities 2.3 Establish and record the correct sequence and order of codes related to a single episode in accordance with standards 2.4 Record data clearly, accurately and completely 2.5 Enter the coded data accurately into the client system appropriate 2.6 Complete the process of assigning the correct codes from clinical data within appropriate timeframes 2.7 Maintain confidentiality of medical records and client information at all times |
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The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:
used current coding manuals and standards to produce accurate and complete coded clinical data from simple medical records for at least 10 different types of patients , including those with:
differing length of stay
both acute and chronic forms of a disease or condition
different service category types
with disease or condition in different contexts (co-existing with multiple comorbidities and complications)
The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:
the broad health industry context for clinical coding
coding factors influencing health status
definition of a clinical coder and clinical coding, and the purpose of coded data
current codes of practice and guidelines in relation to clinical coding, including professional ethics
Australian and relevant state/territory clinical coding standards and protocols
the way rules and conventions are applied to clinical data to achieve correct clinical codes
sequencing protocols for clinical coding, including those for principle and additional diagnoses
timescales within which clinical coding must take place
classifications and nomenclature used to achieve accurate clinical coding
clinical data indexing, storage and mapping from clinical terms of classifications
comprehensive knowledge of medical terminology and body systems
coding classifications relating to:
congenital malformations and deformations
endocrine, nutrition and metabolic diseases
injuries and external causes of injuries
neoplasms
infectious diseases
blood disorders
poisoning and external causes of poisoning
symptoms, signs and abnormal clinical findings
coding classifications for diseases of:
circulatory system
digestive and hepatobiliary system
ear and mastoid process
eye and adnexa
nose and mouth
genitourinary system
musculoskeletal system
nervous system
respiratory system
skin and subcutaneous tissue
coding conditions:
relating to drugs, alcohol and mental health
in pregnancy, childbirth and the puerperium
originating in the perinatal period
Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit:
use of suitable facilities, equipment and resources, including:
real medical records, either electronic or paper based
ICD-10-AM, Australian classification of health interventions (ACHI) and ACS coding manuals
modelling of industry operating conditions, including:
presence of time constraints for coding activities
integration of situations requiring problem solving
Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.