This unit applies to individuals who will be assigned tasks by a senior receptionist or practice manager. They are skilled operators and apply a broad range of competencies in various medical administration contexts. They may exercise discretion and judgement in accessing and maintaining patient records while fully respecting patient privacy and the confidentiality of their details.

BSBMED401B Manage patient record keeping system, covers the management of the system within which this person works.

ELEMENT

PERFORMANCE CRITERIA

1. Identify and clarify own role and procedures for patient record keeping

1.1. Determine own role and responsibilities within patient record keeping system through consultation with relevant personnel or via organisational policy and procedures manual

1.2. Access documented procedures for patient record keeping 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 files following organisational policy and procedures

3. Help maintain records

3.1. Make checks of patient files

3.2. Carry out archiving of patient files as required

3.3. Transfer patient files 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

Required skills

planning and organising skills to access and maintain records

communication skills to receive and clarify instructions

analysis skills to identify and address gaps in own knowledge.

Required knowledge

occupational health and safety (OHS), for example:

manual lifting of materials

ergonomics associated with using computers and own work station

relevant legislation from all levels of government that affects business operations, codes of practice and national standards, such as:

anti-discrimination legislation

ethical principles

privacy laws

Freedom of Information Act.

specific legislation related to patient records

organisation policies and procedures related to:

patient record keeping

privacy and confidentiality

access to records

filing systems and record management processes

medical coding as required to access and maintain patient records.

The Evidence Guide provides advice on assessment and must be read in conjunction with the performance criteria, required skills and knowledge, range statement and the Assessment Guidelines for the Training Package.

Overview of assessment

Critical aspects for assessment and evidence required to demonstrate competency in this unit

Evidence of the following is essential:

using record and file management systems to ensure organisation and accuracy of practice files

communicating with internal staff and other external health care providers to maintain accuracy of patient data

applying knowledge of the healthcare system, and practice policies and procedures to ensure accessibility of records.

Context of and specific resources for assessment

Assessment must ensure:

access to records system

documented procedures

access to an actual workplace or simulated environment

access to office equipment and resources.

Method of assessment

A range of assessment methods should be used to assess practical skills and knowledge. The following examples are appropriate for this unit:

direct questioning combined with review of portfolios of evidence and third party workplace reports of on-the-job performance by the candidate

review of new records created

analysis of responses to case studies and scenarios

demonstration of techniques

observation of presentations

oral or written questioning to assess knowledge of workplace emergencies, risks and hazards

observation of performance in role plays

assessment of archived patient files

assessment of recommendations made for improvements to the procedures and processes for maintaining patient records.

Guidance information for assessment

Holistic assessment with other units relevant to the industry sector, workplace and job role is recommended, for example:

other general administration or medical services administration units.

The range statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Bold italicised wording, if used in the performance criteria, is detailed below. Essential operating conditions that may be present with training and assessment (depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts) may also be included.

System may include:

print-based records management systems

software and hardware-based records management systems

Relevant personnel may include:

administrative manager

health professionals

manager of facility

own supervisor

partners in business

Practitioners' instructions may include:

filing documents in records

making further appointments with health professionals within the facility

referral to another health professional

request for a letter of referral to be prepared

Checks of patient files may include:

checking on a pre-determined cycle

checking on specified dates

ensuring files are neat, tidy and correct

ensuring files are stored in correct order (alphabetical, numerical, alphanumeric)

Archiving may include:

archiving on direction and under supervision

file storage using appropriate archiving options such as boxes, external storage facility, electronic scanning and imaging

identification of files for archiving

removal of files from system

Appropriate request for patient information refers to:

legitimate request for patient information agreed to by patient and for purposes of furthering treatment regime with another health facility and within legislative requirements including:

approval by relevant health practitioner

Freedom of Information Act

organisational policy and procedures

Privacy Act

Unit sector

Administration - Medical Services Administration

This unit contains employability skills.