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Evidence Guide: BSBMED401B - Manage patient record keeping system

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

 

BSBMED401B - Manage patient record keeping system

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

Clarify how patient records system operates

  1. Access policies and procedures for patient records
  2. Consult relevant personnel about how the system operates
  3. Determine roles and responsibilities for the system operations
  4. Communicate roles and responsibilities for system operations to relevant personnel
Access policies and procedures for patient records

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consult relevant personnel about how the system operates

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Determine roles and responsibilities for the system operations

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Communicate roles and responsibilities for system operations to relevant personnel

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Manage operation of patient records system

  1. Supervise staff maintaining patient records
  2. Provide staff maintaining patient records with training as required
  3. Regularly consult staff using patient records about system efficacy
  4. Maintain integrity of patient records
  5. Maintain security of patient records
  6. Stress importance of confidentiality of patient records to all staff, including self, who handle or have access to patient files
  7. Provide authorisation of transfer of records from facility according to practice protocols
  8. Archive records as appropriate
Supervise staff maintaining patient records

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide staff maintaining patient records with training as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Regularly consult staff using patient records about system efficacy

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain integrity of patient records

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain security of patient records

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Stress importance of confidentiality of patient records to all staff, including self, who handle or have access to patient files

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Archive records as appropriate

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Review and improve patient records system

  1. Monitor and review implementation of the system to identify improvements
  2. Make recommendations to relevant personnel for system improvements
  3. Implement approved recommendations
  4. Supervise staff maintaining patient records to implement changes
  5. Plan and deliver any required training for staff to implement changes made to the system
Monitor and review implementation of the system to identify improvements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Make recommendations to relevant personnel for system improvements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement approved recommendations

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Supervise staff maintaining patient records to implement changes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Plan and deliver any required training for staff to implement changes made to the system

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

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.

Required Skills and Knowledge

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.

Range Statement

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