Elements and Performance Criteria
- Abstract clinical data from moderately complex medical records
- Interpret and apply the Australian National Coding Standards to identify clinical data from moderately complex discharge summaries, medical reports and 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 Australian National Coding Standards 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 ICD-10-AM disease and ACHI procedure codes
- Utilise resources 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 occupational 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