Application
This unit describes the skills and knowledge required to maintain patient records within an existing medical records management system, under the supervision of a senior receptionist or practice manager.
It applies to individuals who apply a broad range of competencies in various medical administration contexts. They are skilled operators who are expected to exercise discretion and judgement in accessing and maintaining patient records while fully respecting patient privacy and the confidentiality of their details.
No licensing, legislative, regulatory or certification requirements apply to this unit at the time of publication.
Elements and Performance Criteria
ELEMENT | PERFORMANCE CRITERIA |
Elements describe the essential outcomes. | Performance criteria describe the performance needed to demonstrate achievement of the element. |
1. Identify and clarify own role and procedures for patient recordkeeping | 1.1 Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual 1.2 Access documented procedures for patient recordkeeping system and read for understanding 1.3 Seek clarification with relevant personnel of unclear or ambiguous procedures |
2. Access patient records | 2.1 Gain access to patient records to facilitate patient visit 2.2 Check currency and accuracy of patient demographic and personal details 2.3 Create new records according to enterprise protocols 2.4 Check records following patient visits, for practitioners’ instructions related to follow-up action 2.5 Store patient records according to organisational policy and procedures |
3. Help maintain records | 3.1 Make required checks of patient records 3.2 Carry out archiving of patient records as required 3.3 Transfer patient records to another health facility upon appropriate request for patient information |
4. Monitor and review own role | 4.1 Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices 4.2 Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records |
Evidence of Performance
Evidence of the ability to:
use a recordkeeping system to create, access, store and maintain accurate records, according to organisational and legislative requirements
identify and recommend improvements to recordkeeping system or own work practices
communicate with relevant people about patient records.
Note: if a specific volume or frequency is not stated, then evidence must be provided at least once.
Evidence of Knowledge
To complete the unit requirements safely and effectively, the individual must:
outline relevant legislation, standards and/or codes of practice that affect patient recordkeeping
explain workplace policies and procedures related to patient recordkeeping, including privacy and confidentiality
describe the process used to set up and maintain a patient record
explain how coding systems help users to access and to maintain patient records.
Assessment Conditions
Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the medical services administration field of work and include access to:
a recordkeeping system
documented procedures
case studies and, where possible, real situations
office equipment and resources.
Assessors of this unit must satisfy the requirements for assessors in applicable vocational education and training legislation, frameworks and/or standards.
Foundation Skills
This section describes language, literacy, numeracy and employment skills incorporated in the performance criteria that are required for competent performance.
Skill | Performance Criteria | Description |
Reading | 1.1, 1.2, 1.3, 2.2, 2.3, 2.4, 2.5, 3.1, 3.2, 4.2 | Recognises and interprets a range of everyday workplace information including organisational procedures and medical data |
Writing | 2.3, 3.2, 3.3, 4.2 | Creates and maintains records according to organisational requirements Documents recommendations for improved processes using simple vocabulary and required structure |
Oral Communication | 1.1, 1.3, 4.2 | Uses specific vocabulary and active listening and questioning techniques to confirm understanding |
Navigate the world of work | 1.1, 2.3, 2.5, 3.3 | Identifies and works within own roles and responsibilities according to organisational and legislative requirements |
Interact with others | 1.1, 1.3, 3.3, 4.2 | Uses appropriate practices and protocols for workplace communication Collaborates with others to achieve results in immediate work context |
Get the work done | 1.1, 2.1, 2.5, 3.1-3.3, 4.1, 4.2 | Plans and sequences workload to ensure tasks are completed in a timely manner Uses analytical skills to determine recommendations for improvement to established processes and procedures |
Sectors
Administration – Medical Services Administration