Unit of competency details

Descriptor 

This unit of competency describes the skills and knowledge required to accurately extract the correct clinical data from simple medical records

Application 

Work performed requires a range of well developed skills where some discretion and judgement is required and individuals will take responsibility for their own outputs

Employability Skills 

This unit contains Employability Skills

Elements define the essential outcomes of a unit of competency.

The Performance Criteria specify the level of performance required to demonstrate achievement of the Element. Terms in italics are elaborated in the Range Statement.

ELEMENT 

PERFORMANCE CRITERIA 

1. Identify and evaluate clinical data from simple medical records 

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

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

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 primary 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 ICD -10 -AM disease and procedures codes  abstracted from simple medical records

2.2 Apply Australian National Coding Standards where appropriate, to ensure the correct assignment of codes

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 Maintain confidentiality at all times

2.6 Enter the coded data accurately into the client appropriate system 

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

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
• 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 factors influencing health status
• Coding requirements of:

• congenital malformations and deformations
• endocrine, nutrition and metabolic diseases
• injuries and external causes of injuries
• neoplasms
• poisoning and external causes of poisoning
• symptoms, signs and abnormal clinical findings

• Coding diseases of the:

• circulatory system
• digestive system
• ear and mastoid process
• eye and adnexa
• genitourinary system
• musculoskeletal system
• nervous system
• respiratory system
• skin and subcutaneous tissue

• Coding conditions:

• in pregnancy, childbirth and the puerperium
• originating in the perinatal period

• Current codes of practice and guidelines in relation to clinical coding
• Definition of a clinical coder and clinical coding, and the purpose of coded data
• Professional ethics in clinical coding
• Sequencing of codes and primary diagnosis
• The way rules and conventions are applied to clinical data to achieve correct clinical codes
• Timescales within which clinical coding must take place

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 simple medical records to produce coded clinical data
• Apply Australian Coding Standards at an introductory coding level to simple medical records
• Assign complete and accurate codes for diseases, conditions, injuries and procedures
• Identify principal diagnosis and principal procedures
• Use ICD-10-AM coding manuals

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 :

• Relevant guidelines, standards and procedures
• Resources essential for assessment include:

• ICD-10-AM, ACHI and ACS and relevant local coding requirements
• simple medical records

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.

Simple medical records may include 

A medical record generated by an episode of care involving one of the following:

• Day stay
• Day surgery
• Planned surgery
• Simple medical problems in episodes of care not exceeding a length of stay (LOS) of three days

Diagnosis may include :

• Diagnosis of:

• congenital malformations and deformations
• endocrine, nutrition and metabolic diseases
• injuries and external causes of injuries
• neoplasms
• poisoning and external causes of poisoning
• symptoms, signs and abnormal clinical findings

• Diagnosis of diseases of the:

• circulatory system
• digestive system
• ear and mastoid process
• eye and adnexa
• genitourinary system
• musculoskeletal system
• nervous system
• respiratory system
• skin and subcutaneous tissue

• Diagnosis:

• in pregnancy, childbirth and the puerperium
• originating in the perinatal period

Clinical coding requirements may include :

• Coding requirements of:

• congenital malformations and deformations
• endocrine, nutrition and metabolic diseases
• injuries and external causes of injuries
• neoplasms
• poisoning and external causes of poisoning
• symptoms, signs and abnormal clinical findings

• Coding diseases of the:

• circulatory system
• digestive system
• ear and mastoid process
• eye and adnexa
• genitourinary system
• musculoskeletal system
• nervous system
• respiratory system
• skin and subcutaneous tissue

• Coding conditions:

• in pregnancy, childbirth and the puerperium
• originating in the perinatal period

Client information systems may include 

• Computerised systems
• Manual systems