Complete highly complex clinical coding

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 HLTADM007, 'Complete highly complex clinical coding'.
Google Links
links to google searches, with filtering in place to maximise the usefulness of the returned results
Reference books for 'Complete highly complex clinical coding' on This online store has a huge range of books, pretty reasonable prices, free delivery in Australia *and* they give a small commission to for every purchase, so go nuts :)

Elements and Performance Criteria



Elements define the essential outcomes

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

1. Abstract clinical data from highly complex medical records

1.1 Abstract appropriate conditions/diseases and procedures from highly complex medical records from a range of specialties

1.2 Interpret and apply the Australian coding standards (ACS) to ensure correct assignment of codes from a varied and highly complex casemix

1.3 Identify the principal diagnosis and principal procedure for an admission when coding a varied and highly complex casemix

1.4 Identify additional diagnoses and procedures when coding a varied and highly complex casemix

2. Assign codes relating to highly complex medical records

2.1 Perform clinical coding on a broad casemix, utilising knowledge of medical science and applying International statistical classification of diseases and related health problems (ICD-10-AM), Australian classification of health interventions (ACHI) and ACS new edition changes

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

2.3 Assign complete and accurate ICD-10-AM disease and ACHI procedure codes abstracted from a varied and highly complex casemix

2.4 Utilise appropriateresources to make informed coding decisions relating to highly complex medical records

2.5 Ensure coding reflects the correct sequencing of diagnoses and procedures

2.6 Identify coding issues and determine appropriate solutions

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

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

2.9 Meet occupational health and safety duty of care requirements

3. Provide clinical coding expertise in the workplace

3.1 Add value to discussions regarding clinical coding within the coding unit

3.2 Provide mentoring support for entry level clinical coders

3.3 Supervise an entry level clinical coder and select appropriate medical records for them

3.4 Follow up with clinicians regarding ambiguities in documentation, where required

3.5 Conduct research using appropriate materials/ resources and or clinical input to generate solutions to address clinical coding issues

4. Maintain currency of data collection and coding

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

4.2 Secure and interpret changes to data collection and coding requirements, according to relevant standards, protocols and legislation

4.3 Identify necessary amendments to data collection and coding activities

4.4 Provide necessary information and training to ensure that amendments are implemented with maximum ease

4.5 Ensure computer software is updated to meet any adjustment needs

4.6 Monitor the implementation of amendments