Assessment Requirements for HLTADM005 Produce coded clinical data

Release: 1

Assessment Requirements for HLTADM005 Produce coded clinical data

Modification History

Release	Comments
Release 1	This version was released in HLT Health Training Package release 2.0 and meets the requirements of the 2012 Standards for Training Packages. Minimal changes to the elements and performance criteria. New evidence requirements for assessment, including volume and frequency.

Performance Evidence

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 simple medical records for at least 10 different types of 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)

Knowledge Evidence

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

Assessment Conditions

Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit:

use of suitable facilities, equipment and resources, including:

real medical records, either electronic or paper based

ICD-10-AM, Australian classification of health interventions (ACHI) and ACS coding manuals

modelling of industry operating conditions, including:

presence of time constraints for coding activities

integration of situations requiring problem solving

Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705