Elements and Performance Criteria
- Elements define the essential outcomes
- Abstract clinical data from moderately complex medical records
- Interpret and apply the Australian coding standards (ACS) to identify clinical data from moderately complex medical records
- Select appropriate conditions/diseases and procedures for coding from moderately complex medical records
- Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records
- Identify additional diagnoses and procedures
- Establish the correct sequencing of diagnoses and procedures
- Assign codes relating to moderately complex medical records
- Apply ACS where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties
- Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease codes and Australian Classification of Health Interventions (ACHI) procedure codes
- Utiliseresources where appropriate to assist in making coding decisions
- Recognise problems relating to privacy and confidentiality of client information
- Maintain confidentiality of medical records and client information at all times
- Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes
- Meet work health and safety duty of care requirements
- Maintain clinical coding records
- Record, enter, edit and maintain a client information system of coded data (disease index)
- Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation
- Make amendments to data collection and coding activities in line with organisation requirements
- Maintain and update own knowledge and skills to ensure that amendments are addressed as required