Elements and Performance Criteria
- Elements define the essential outcomes
- Identify and evaluate clinical data from simple medical records
- Identify the principal diagnosis and principal procedure for an admission when coding from a simple medical record
- Identify additional diagnosis and procedures when coding from a simple medical record with specialties
- Refer any issues concerning clarity and accuracy of the clinical data to the appropriate person
- Evaluate the relevance of other health conditions and factors affecting the patient to establish the principal diagnosis
- . Establish the appropriate level of detail of clinical data to meet standards
- Record, enter, edit and maintain a client information system of coded data (disease index)
- Identify the correct clinical data within appropriate timeframes
- Assign codes to clinical data
- Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease and procedures codesabstracted from simple medical records
- Apply Australian coding standards (ACS) where appropriate, to ensure the correct assignment of codes when coding simple medical records for specialities
- Establish and record the correct sequence and order of codes related to a single episode in accordance with standards
- Record data clearly, accurately and completely
- Enter the coded data accurately into the client system appropriate
- Complete the process of assigning the correct codes from clinical data within appropriate timeframes
- Maintain confidentiality of medical records and client information at all times