This unit applies to individuals managing an existing record keeping 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 facility.

The unit does not cover the design of a new system but does cover reviews and improvements to an existing system.

BSBMED303B Maintain patient records, covers the day to day implementation of the system.

ELEMENT

PERFORMANCE CRITERIA

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, including self, who handle or have access to patient files

2.7. Provide authorisation of transfer of records from facility according to practice protocols

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

Required skills

management skills to supervise staff

analysis skills to continuously improve procedures through reviewing, and identifying and implementing improvements.

Required knowledge

occupational health and safety (OHS), for example:

manual lifting

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

consumer laws including appropriate state legislation

ethical principles

privacy laws

statutory regulations for records

specific legislation related to patient records

enterprise policies and procedures related to:

patient record keeping including archiving and records transfer

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:

managing a patient record keeping system over a significant period

documenting how records have been accessed and archived by staff or self

demonstrating how records have been provided to support relevant medical activities

knowledge of relevant legislation from all levels of government.

Context of and specific resources for assessment

Assessment must ensure:

access to an actual workplace or simulated environment

access to office equipment and resources

examples of documents and records for archiving

access to records system

documented procedures.

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 archived records

analysis of responses to case studies and scenarios

demonstration of techniques

observation of presentations

oral or written questioning to assess knowledge of filing systems and record management processes

observation of performance in role plays.

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.

Relevant personnel may include:

chief executive officer, director or manager of the business

external bodies including peak industry organisations

health professionals using the system

partners in the business

reception staff

staff managing patient records

System may include:

software and hardware-based records management systems

print-based records management systems

Supervising staff may include:

coaching/mentoring

documenting procedures and processes

formal training

Authorisation of transfer of records may occur in relation to:

organisational policy

organisational procedure

relevant laws

Unit sector

Administration - Medical Services Administration

This unit contains employability skills.