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Evidence Guide: BSBMED303 - Maintain patient records

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

 

BSBMED303 - Maintain patient records

What evidence can you provide to prove your understanding of each of the following citeria?

Identify and clarify own role and procedures for patient recordkeeping

  1. Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual
  2. Access documented procedures for patient recordkeeping system and read for understanding
  3. Seek clarification with relevant personnel of unclear or ambiguous procedures
Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Access documented procedures for patient recordkeeping system and read for understanding

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Seek clarification with relevant personnel of unclear or ambiguous procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Access patient records

  1. Gain access to patient records to facilitate patient visit
  2. Check currency and accuracy of patient demographic and personal details
  3. Create new records according to enterprise protocols
  4. Check records following patient visits, for practitioners’ instructions related to follow-up action
  5. Store patient files following organisational policy and procedures
Gain access to patient records to facilitate patient visit

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Check currency and accuracy of patient demographic and personal details

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Create new records according to enterprise protocols

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Check records following patient visits, for practitioners’ instructions related to follow-up action

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Store patient files following organisational policy and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Help maintain records

  1. Make checks of patient files
  2. Carry out archiving of patient files as required
  3. Transfer patient files to another health facility upon appropriate request for patient information
Make checks of patient files

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Carry out archiving of patient files as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Transfer patient files to another health facility upon appropriate request for patient information

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Monitor and review own role

  1. Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices
  2. Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records
Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

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

Required Skills and Knowledge

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 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.

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.