Produce coded clinical data

Formats and tools

Unit Description
Reconstruct the unit from the xml and display it as an HTML page.
Assessment Tool
an assessor resource that builds a framework for writing an assessment tool
Assessment Template
generate a spreadsheet for marking this unit in a classroom environment. Put student names in the top row and check them off as they demonstrate competenece for each of the unit's elements and performance criteria.
Assessment Matrix
a slightly different format than the assessment template. A spreadsheet with unit names, elements and performance criteria in separate columns. Put assessment names in column headings to track which performance criteria each one covers. Good for ensuring that you've covered every one of the performance criteria with your assessment instrument (all assessement tools together).
Wiki Markup
mark up the unit in a wiki markup codes, ready to copy and paste into a wiki page. The output will work in most wikis but is designed to work particularly well as a Wikiversity learning project.
Evidence Guide
create an evidence guide for workplace assessment and RPL applicants
Competency Mapping Template
Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners. A template for developing assessments for a unit, which will help you to create valid, fair and reliable assessments for the unit, ready to give to trainers and students
Observation Checklist
create an observation checklist for workplace assessment and RPL applicants. This is similar to the evidence guide above, but a little shorter and friendlier on your printer. You will also need to create a seperate Assessor Marking Guide for guidelines on gathering evidence and a list of key points for each activity observed using the unit's range statement, required skills and evidence required (see the unit's html page for details)

Self Assessment Survey
A form for students to assess thier current skill levels against each of the unit's performance criteria. Cut and paste into a web document or print and distribute in hard copy.
Moodle Outcomes
Create a csv file of the unit's performance criteria to import into a moodle course as outcomes, ready to associate with each of your assignments. Here's a quick 'how to' for importing these into moodle 2.x
Registered Training Organisations
Trying to find someone to train or assess you? This link lists all the RTOs that are currently registered to deliver HLTADM005, 'Produce coded clinical data'.
Google Links
links to google searches, with filtering in place to maximise the usefulness of the returned results
Books
Reference books for 'Produce coded clinical data' on fishpond.com.au. This online store has a huge range of books, pretty reasonable prices, free delivery in Australia *and* they give a small commission to ntisthis.com for every purchase, so go nuts :)


Elements and Performance Criteria

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