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Evidence Guide: HLTADM005 - Produce coded clinical data

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

 

HLTADM005 - Produce coded clinical data

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

Elements define the essential outcomes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify and evaluate clinical data from simple medical records

  1. Identify the principal diagnosis and principal procedure for an admission when coding from a simple medical record
  2. Identify additional diagnosis and procedures when coding from a simple medical record with specialties
  3. Refer any issues concerning clarity and accuracy of the clinical data to the appropriate person
  4. Evaluate the relevance of other health conditions and factors affecting the patient to establish the principal diagnosis
  5. . Establish the appropriate level of detail of clinical data to meet standards
  6. Record, enter, edit and maintain a client information system of coded data (disease index)
  7. Identify the correct clinical data within appropriate timeframes
Identify the principal diagnosis and principal procedure for an admission when coding from a simple medical record

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify additional diagnosis and procedures when coding from a simple medical record with specialties

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Refer any issues concerning clarity and accuracy of the clinical data to the appropriate person

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Evaluate the relevance of other health conditions and factors affecting the patient to establish the principal diagnosis

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

. Establish the appropriate level of detail of clinical data to meet standards

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record, enter, edit and maintain a client information system of coded data (disease index)

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify the correct clinical data within appropriate timeframes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assign codes to clinical data

  1. Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease and procedures codesabstracted from simple medical records
  2. Apply Australian coding standards (ACS) where appropriate, to ensure the correct assignment of codes when coding simple medical records for specialities
  3. Establish and record the correct sequence and order of codes related to a single episode in accordance with standards
  4. Record data clearly, accurately and completely
  5. Enter the coded data accurately into the client system appropriate
  6. Complete the process of assigning the correct codes from clinical data within appropriate timeframes
  7. Maintain confidentiality of medical records and client information at all times
Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease and procedures codesabstracted from simple medical records

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apply Australian coding standards (ACS) where appropriate, to ensure the correct assignment of codes when coding simple medical records for specialities

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Establish and record the correct sequence and order of codes related to a single episode in accordance with standards

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record data clearly, accurately and completely

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Enter the coded data accurately into the client system appropriate

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Complete the process of assigning the correct codes from clinical data within appropriate timeframes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain confidentiality of medical records and client information at all times

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Identify and evaluate clinical data from simple medical records

1.1 Identify the principal diagnosis and principal procedure for an admission when coding from a simple medical record

1.2 Identify additional diagnosis and procedures when coding from a simple medical record with specialties

1.3 Refer any issues concerning clarity and accuracy of the clinical data to the appropriate person

1.4 Evaluate the relevance of other health conditions and factors affecting the patient to establish the principal diagnosis

1.5. Establish the appropriate level of detail of clinical data to meet standards

1.6 Record, enter, edit and maintain a client information system of coded data (disease index)

1.7 Identify the correct clinical data within appropriate timeframes

2. Assign codes to clinical data

2.1 Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease and procedures codesabstracted from simple medical records

2.2 Apply Australian coding standards (ACS) where appropriate, to ensure the correct assignment of codes when coding simple medical records for specialities

2.3 Establish and record the correct sequence and order of codes related to a single episode in accordance with standards

2.4 Record data clearly, accurately and completely

2.5 Enter the coded data accurately into the client system appropriate

2.6 Complete the process of assigning the correct codes from clinical data within appropriate timeframes

2.7 Maintain confidentiality of medical records and client information at all times

Required Skills and Knowledge

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Identify and evaluate clinical data from simple medical records

1.1 Identify the principal diagnosis and principal procedure for an admission when coding from a simple medical record

1.2 Identify additional diagnosis and procedures when coding from a simple medical record with specialties

1.3 Refer any issues concerning clarity and accuracy of the clinical data to the appropriate person

1.4 Evaluate the relevance of other health conditions and factors affecting the patient to establish the principal diagnosis

1.5. Establish the appropriate level of detail of clinical data to meet standards

1.6 Record, enter, edit and maintain a client information system of coded data (disease index)

1.7 Identify the correct clinical data within appropriate timeframes

2. Assign codes to clinical data

2.1 Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease and procedures codesabstracted from simple medical records

2.2 Apply Australian coding standards (ACS) where appropriate, to ensure the correct assignment of codes when coding simple medical records for specialities

2.3 Establish and record the correct sequence and order of codes related to a single episode in accordance with standards

2.4 Record data clearly, accurately and completely

2.5 Enter the coded data accurately into the client system appropriate

2.6 Complete the process of assigning the correct codes from clinical data within appropriate timeframes

2.7 Maintain confidentiality of medical records and client information at all times

The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:

used current coding manuals and standards to produce accurate and complete coded clinical data from simple medical records for at least 10 different types of patients , including those with:

differing length of stay

both acute and chronic forms of a disease or condition

different service category types

with disease or condition in different contexts (co-existing with multiple comorbidities and complications)

The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:

the broad health industry context for clinical coding

coding factors influencing health status

definition of a clinical coder and clinical coding, and the purpose of coded data

current codes of practice and guidelines in relation to clinical coding, including professional ethics

Australian and relevant state/territory clinical coding standards and protocols

the way rules and conventions are applied to clinical data to achieve correct clinical codes

sequencing protocols for clinical coding, including those for principle and additional diagnoses

timescales within which clinical coding must take place

classifications and nomenclature used to achieve accurate clinical coding

clinical data indexing, storage and mapping from clinical terms of classifications

comprehensive knowledge of medical terminology and body systems

coding classifications relating to:

congenital malformations and deformations

endocrine, nutrition and metabolic diseases

injuries and external causes of injuries

neoplasms

infectious diseases

blood disorders

poisoning and external causes of poisoning

symptoms, signs and abnormal clinical findings

coding classifications for diseases of:

circulatory system

digestive and hepatobiliary system

ear and mastoid process

eye and adnexa

nose and mouth

genitourinary system

musculoskeletal system

nervous system

respiratory system

skin and subcutaneous tissue

coding conditions:

relating to drugs, alcohol and mental health

in pregnancy, childbirth and the puerperium

originating in the perinatal period