Release 

Comments 

Release 1

This version first released with BSB Business Services Training Package Version 1.0.

ELEMENT 

PERFORMANCE CRITERIA 

Elements describe the essential outcomes.

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

1. Identify and clarify own role and procedures for patient recordkeeping

1.1 Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual

1.2 Access documented procedures for patient recordkeeping system and read for understanding

1.3 Seek clarification with relevant personnel of unclear or ambiguous procedures

2. Access patient records

2.1 Gain access to patient records to facilitate patient visit

2.2 Check currency and accuracy of patient demographic and personal details

2.3 Create new records according to enterprise protocols

2.4 Check records following patient visits, for practitioners’ instructions related to follow-up action

2.5 Store patient files following organisational policy and procedures

3. Help maintain records

3.1 Make checks of patient files

3.2 Carry out archiving of patient files as required

3.3 Transfer patient files to another health facility upon appropriate request for patient information

4. Monitor and review own role

4.1 Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices

4.2 Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records

Skill 

Performance Criteria 

Description 

Reading

1.1, 1.2, 1.3, 2.2, 2.3, 2.4, 2.5, 3.1, 3.2, 4.2

• Recognises and interprets a range of everyday workplace information including organisational protocols and medical data

Writing

2.3, 3.2, 3.3, 4.2

• Creates and maintains records according to organisational requirements
• Documents recommendations for improved processes using simple vocabulary and required structure

Oral Communication

1.1, 1.3, 4.2

• Uses specific vocabulary and active listening and questioning techniques to confirm understanding

Navigate the world of work

1.1, 2.3, 2.5

• Identifies and works within own roles and responsibilities according to organisational procedures and protocols

Interact with others

1.1, 1.3, 4.2

• Selects the appropriate form, channel and mode of communication for a specific purpose related to own work
• Collaborates with others to achieve results in immediate work context

Get the work done

1.1, 2.1, 2.5, 3.1-3.3, 4.1, 4.2

• Plans and sequences workload to ensure tasks are completed accurately and in a timely manner
• Uses analytical skills to determine recommendations for improvement to established processes and procedures

Code and title 

current version 

Code and title 

previous version 

Comments 

Equivalence status 

BSBMED303 Maintain patient records

BSBMED303B Maintain patient records

Updated to meet Standards for Training Packages

Equivalent unit

Release 

Comments 

Release 1

This version first released with BSB Business Services Training Package Version 1.0.