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Evidence Guide: HLTADM006 - Undertake complex clinical coding

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

 

HLTADM006 - Undertake complex clinical coding

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

Elements define the essential outcomes

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Abstract clinical data from moderately complex medical records

  1. Interpret and apply the Australian coding standards (ACS) to identify clinical data from moderately complex medical records
  2. Select appropriate conditions/diseases and procedures for coding from moderately complex medical records
  3. Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records
  4. Identify additional diagnoses and procedures
  5. Establish the correct sequencing of diagnoses and procedures
Interpret and apply the Australian coding standards (ACS) to identify clinical data from moderately complex medical records

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Select appropriate conditions/diseases and procedures for coding from moderately complex medical records

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Identify additional diagnoses and procedures

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Establish the correct sequencing of diagnoses and procedures

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Assign codes relating to moderately complex medical records

  1. Apply ACS where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties
  2. Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease codes and Australian Classification of Health Interventions (ACHI) procedure codes
  3. Utiliseresources where appropriate to assist in making coding decisions
  4. Recognise problems relating to privacy and confidentiality of client information
  5. Maintain confidentiality of medical records and client information at all times
  6. Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes
  7. Meet work health and safety duty of care requirements
Apply ACS where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease codes and Australian Classification of Health Interventions (ACHI) procedure codes

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Utiliseresources where appropriate to assist in making coding decisions

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Recognise problems relating to privacy and confidentiality of client information

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Maintain confidentiality of medical records and client information at all times

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Meet work health and safety duty of care requirements

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Maintain clinical coding records

  1. Record, enter, edit and maintain a client information system of coded data (disease index)
  2. Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation
  3. Make amendments to data collection and coding activities in line with organisation requirements
  4. Maintain and update own knowledge and skills to ensure that amendments are addressed as required
Record, enter, edit and maintain a client information system of coded data (disease index)

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Make amendments to data collection and coding activities in line with organisation requirements

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Maintain and update own knowledge and skills to ensure that amendments are addressed as required

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. Abstract clinical data from moderately complex medical records

1.1 Interpret and apply the Australian coding standards (ACS) to identify clinical data from moderately complex medical records

1.2 Select appropriate conditions/diseases and procedures for coding from moderately complex medical records

1.3 Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records

1.4 Identify additional diagnoses and procedures

1.5 Establish the correct sequencing of diagnoses and procedures

2. Assign codes relating to moderately complex medical records

2.1 Apply ACS where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties

2.2 Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease codes and Australian Classification of Health Interventions (ACHI) procedure codes

2.3 Utiliseresources where appropriate to assist in making coding decisions

2.4 Recognise problems relating to privacy and confidentiality of client information

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

2.6 Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes

2.7 Meet work health and safety duty of care requirements

3. Maintain clinical coding records

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

3.2 Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation

3.3 Make amendments to data collection and coding activities in line with organisation requirements

3.4 Maintain and update own knowledge and skills to ensure that amendments are addressed as required

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. Abstract clinical data from moderately complex medical records

1.1 Interpret and apply the Australian coding standards (ACS) to identify clinical data from moderately complex medical records

1.2 Select appropriate conditions/diseases and procedures for coding from moderately complex medical records

1.3 Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records

1.4 Identify additional diagnoses and procedures

1.5 Establish the correct sequencing of diagnoses and procedures

2. Assign codes relating to moderately complex medical records

2.1 Apply ACS where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties

2.2 Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease codes and Australian Classification of Health Interventions (ACHI) procedure codes

2.3 Utiliseresources where appropriate to assist in making coding decisions

2.4 Recognise problems relating to privacy and confidentiality of client information

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

2.6 Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes

2.7 Meet work health and safety duty of care requirements

3. Maintain clinical coding records

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

3.2 Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation

3.3 Make amendments to data collection and coding activities in line with organisation requirements

3.4 Maintain and update own knowledge and skills to ensure that amendments are addressed as required

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 moderately complex medical records across all specialities including:

discharge summaries

medical reports

medical records

produced accurate and complete coded clinical data for at least 20 different types 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