Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners

HLTADM005 Mapping and Delivery Guide
Produce coded clinical data

Version 1.0
Issue Date: April 2024


Qualification -
Unit of Competency HLTADM005 - Produce coded clinical data
Description
Employability Skills
Learning Outcomes and Application This unit describes the skills and knowledge required to extract the correct clinical data from simple medical records. A simple medical record is defined as a medical record generated by an episode of care involving day stay, day surgery, planned surgery or simple medical problems with an average length of stay.This unit applies to clinical coders.The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.
Duration and Setting X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.

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.
Prerequisites/co-requisites
Competency Field
Development and validation strategy and guide for assessors and learners Student Learning Resources Handouts
Activities 		Slides
PPT 		Assessment 1 Assessment 2 Assessment 3 Assessment 4
Elements of Competency Performance Criteria              
Element: Elements define the essential outcomes
       
Element: 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
       
Element: 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
       


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 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

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

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

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assignment, 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 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

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

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
 
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 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 

Forms

Assessment Cover Sheet

HLTADM005 - Produce coded clinical data
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

HLTADM005 - Produce coded clinical data

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: