Application
This unit describes the skills and knowledge required to manage a patient recordkeeping system within a medical environment and to supervise others. It covers clarifying roles and responsibilities, managing the operation of a patient recordkeeping system, and reviewing and improving the system. The unit does not cover the design of a new system but does cover reviews and improvements to an existing system.
It applies to individuals managing an existing recordkeeping system (and sub-systems within the overall system) in a medical context. It may involve supervising the work of other personnel who implement the system and maintain patient records day-to-day. It also involves working with users of the system such as the health practitioners in the enterprise.
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. Clarify how patient records system operates | 1.1 Access policies and procedures for patient records 1.2 Consult relevant personnel about how the system operates 1.3 Determine roles and responsibilities for the system operations 1.4 Communicate roles and responsibilities for system operations to relevant personnel |
2. Manage operation of patient records system | 2.1 Supervise staff maintaining patient records 2.2 Provide staff maintaining patient records with training as required 2.3 Regularly consult staff using patient records about system efficacy 2.4 Maintain integrity of patient records 2.5 Maintain security of patient records 2.6 Stress importance of confidentiality of patient records to all staff, who handle or have access to patient files 2.7 Provide authorisation of transfer of records from the workplace according to policies and procedures 2.8 Archive records as appropriate |
3. Review and improve patient records system | 3.1 Monitor and review implementation of the system to identify improvements 3.2 Make recommendations to relevant personnel for system improvements 3.3 Implement approved recommendations 3.4 Supervise staff maintaining patient records to implement changes 3.5 Plan and deliver any required training for staff to implement changes made to the system |
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, 1.3, 1.4, 2.1, 2.5, 2.7, 2.8, 3.1-3.5 | Identifies and interprets relevant information and ideas within organisational texts |
Writing | 1.4, 2.1, 2.2, 2.3, 2.4, 2.7, 2.8, 3.1-3.5 | Creates and maintains records using required words and codes Prepares documentations for others using words and style appropriate to audience and context |
Oral Communication | 1.2, 1.4, 2.1, 2.2, 2.3, 2.6, 3.2, 3.4, 3.5 | Communicates with relevant personnel and uses everyday language to train or supervise staff Asks questions and listens for relevant information in oral texts |
Navigate the world of work | 1.1, 1.3, 2.6 | Identifies and works according to roles and responsibilities, policies and procedures Ensures own and others behaviour is consistent with the expected policies, procedures and responsibilities related to privacy, confidentiality and security in a medical environment |
Interact with others | 1.2, 1.4, 2.1, 2.2, 2.3, 3.2, 3.4, 3.5 | Collaborates with relevant personnel to ensure understanding of the records system Selects and uses appropriate communication practices when providing training or feedback to others |
Get the work done | 1.1-1.4, 2.1-2.5, 2.8, 3.1-3.5 | Plans and organises own and others' tasks to ensure work is completed according to legislative and organisational requirements Uses analytical processes to determine opportunities for improvements to processes |
Sectors
Administration – Medical Services Administration