NTISthis.com

Evidence Guide: HLTCC401B - 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

 

HLTCC401B - Undertake complex clinical coding

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

Abstract clinical data from moderately complex medical records

  1. Interpret and apply the Australian National Coding Standards to identify clinical data from moderately complex discharge summaries, medical reports and 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 National Coding Standards to identify clinical data from moderately complex discharge summaries, medical reports and 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 Australian National Coding Standards 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 ICD-10-AM disease and ACHI procedure codes
  3. Utilise resources 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 occupational health and safety duty of care requirements
Apply Australian National Coding Standards 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 ICD-10-AM disease and ACHI procedure codes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Utilise resources 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 occupational 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

The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.

Critical aspects for assessment and evidence required to demonstrate this competency unit:

The individual being assessed must provide evidence of specified essential knowledge as well as skills

Consistency of performance should be demonstrated over the required range of situations relevant to the workplace

Access and equity considerations:

All workers in the health industry should be aware of access and equity issues in relation to their own area of work

All workers should develop their ability to work in a culturally diverse environment

In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people

Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities

Context of and specific resources for assessment:

Assessment must be completed in the workplace

Relevant guidelines, standards and procedures

Resources essential for assessment include:

ICD-10-AM, ACHI and ACS and relevant local coding requirements

a range of complex medical records

resources material

Required Skills and Knowledge

This describes the essential skills and knowledge and their level required for this unit.

Essential knowledge:

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes knowledge of:

Australian and relevant State/Territory clinical coding standards and protocols

Appropriate legislation

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

Professional ethics in clinical coding

Classifications and nomenclature used to achieve accurate clinical coding

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

Coding diseases and procedures with ICD-10-AM, ACHI and ACS coding manuals

Coding factors influencing health status

Coding relating to:

infectious and blood diseases

mental health

endocrine and musculoskeletal diseases

injuries and poisonings

neoplasms, digestive and skin diseases

respiratory and circulatory diseases

nervous system, eye, ear, nose and mouth diseases

genitourinary, pregnancy, childbirth, the puerperium, the perinatal period and congenital conditions

Comprehensive knowledge of medical terminology and body systems

Current codes of practice and guidelines in relation to clinical coding

Sequencing of primary and additional diagnoses

Sequencing protocols for clinical coding

Sources of information relating to changes to clinical coding requirements

Timeframes for completing clinical coding

Essential skills:

It is critical that the candidate demonstrate the ability to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes the ability to:

Analyse moderately complex medical records from a range of specialties to produce coded clinical data

Apply Australian National Coding Standards to code moderately complex medical records

Complete coding of an average of four moderately complex medical records per hour

Enter data to at least 80%accuracy from moderately complex medical records

Identify necessary amendments to data collection and coding activities

Identify sequencing requirements in moderately complex medical records

Use appropriate resources to assist with moderately complex clinical coding requirements

Use ICD-10-AM, ACHI and ACS coding manuals

Use manual or an interfaced computerised coding system to submit data or disease index

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. Add any 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.

Moderately complex medical records refer to:

Medical records resulting from an episode of care generally seen in health care facilities ranging from large to small size hospitals (AIHW National Hospital Peer Group Classifications A1-D1)

Medical information may be obtained from:

discharge summaries

medical reports

medical records

Resources may include:

MIMS

Medical abbreviations dictionary

Disease and procedure codes may include:

Coding for:

endocrine and musculoskeletal diseases

genitourinary, pregnancy, childbirth, the puerperium, the perinatal period and congenital conditions

infectious and blood diseases

injuries and poisonings

mental health

neoplasms, digestive and skin diseases

nervous system, eye, ear, nose and mouth diseases

respiratory and circulatory diseases

Client information systems may include:

Computerised systems

Manual systems