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.

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

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 procedures 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, 3.3

• Identifies and works within own roles and responsibilities according to organisational and legislative requirements

Interact with others

1.1, 1.3, 3.3, 4.2

• Uses appropriate practices and protocols for workplace communication
• 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 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

Release 2

BSBMED303 Maintain patient records

Release 1

Updated to clarify intent

Equivalent unit

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.