Unit of competency
Modification History
Release |
Comments |
Release 2 |
This version released with BSB Business Services Training Package Version 2.0. Version created to clarify intent. |
Release 1 |
This version first released with BSB Business Services Training Package Version 1.0. |
Application
This unit describes the skills and knowledge required to maintain patient records within an existing medical records management system, under the supervision of a senior receptionist or practice manager.
It applies to individuals who apply a broad range of competencies in various medical administration contexts. They are skilled operators who are expected to exercise discretion and judgement in accessing and maintaining patient records while fully respecting patient privacy and the confidentiality of their details.
No licensing, legislative, regulatory or certification requirements apply to this unit at the time of publication.
Unit Sector
Administration – Medical Services Administration
Elements and Performance Criteria
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 records according to organisational policy and procedures |
3. Help maintain records |
3.1 Make required checks of patient records 3.2 Carry out archiving of patient records as required 3.3 Transfer patient records 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 |
Foundation Skills
This section describes language, literacy, numeracy and employment skills incorporated in the performance criteria that are required for competent performance.
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 |
|
Writing |
2.3, 3.2, 3.3, 4.2 |
|
Oral Communication |
1.1, 1.3, 4.2 |
|
Navigate the world of work |
1.1, 2.3, 2.5, 3.3 |
|
Interact with others |
1.1, 1.3, 3.3, 4.2 |
|
Get the work done |
1.1, 2.1, 2.5, 3.1-3.3, 4.1, 4.2 |
|
Unit Mapping Information
Code and title current version |
Code and title previous version |
Comments |
Equivalence status |
BSBMED303 Maintain patient records Release 2 |
BSBMED303 Maintain patient records Release 1 |
Updated to clarify intent |
Equivalent unit |
Links
Companion Volume implementation guides are found in VETNet - https://vetnet.gov.au/Pages/TrainingDocs.aspx?q=11ef6853-ceed-4ba7-9d87-4da407e23c10