Unit of competency details

BSBMED401 - Manage patient recordkeeping system (Release 1)

Summary

Releases:
ReleaseStatusRelease date
1 1 (this release)Current 25/Mar/2015

Usage recommendation:
Current
Mapping:
MappingNotesDate
Supersedes and is equivalent to BSBMED401B - Manage patient record keeping systemUpdated to meet Standards for Training Packages 24/Mar/2015


Training packages that include this unit

Classifications

SchemeCodeClassification value
ASCED Module/Unit of Competency Field of Education Identifier 080901 Secretarial And Clerical Studies  

Classification history

SchemeCodeClassification valueStart dateEnd date
ASCED Module/Unit of Competency Field of Education Identifier 080901 Secretarial And Clerical Studies  30/Jul/2015 
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Unit Of competency

Modification History

Release 

Comments 

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 manage a patient recordkeeping system within a medical environment and to supervise others. It covers clarifying roles and responsibilities, managing the operation of a patient recordkeeping system, and reviewing and improving the system. The unit does not cover the design of a new system but does cover reviews and improvements to an existing system.

It applies to individuals managing an existing recordkeeping system (and sub-systems within the overall system) in a medical context. It may involve supervising the work of other personnel who implement the system and maintain patient records day-to-day. It also involves working with users of the system such as the health practitioners in the enterprise.

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. Clarify how patient records system operates

1.1 Access policies and procedures for patient records

1.2 Consult relevant personnel about how the system operates

1.3 Determine roles and responsibilities for the system operations

1.4 Communicate roles and responsibilities for system operations to relevant personnel

2. Manage operation of patient records system

2.1 Supervise staff maintaining patient records

2.2 Provide staff maintaining patient records with training as required

2.3 Regularly consult staff using patient records about system efficacy

2.4 Maintain integrity of patient records

2.5 Maintain security of patient records

2.6 Stress importance of confidentiality of patient records to all staff, who handle or have access to patient files

2.7 Provide authorisation of transfer of records from the workplace according to policies and procedures

2.8 Archive records as appropriate

3. Review and improve patient records system

3.1 Monitor and review implementation of the system to identify improvements

3.2 Make recommendations to relevant personnel for system improvements

3.3 Implement approved recommendations

3.4 Supervise staff maintaining patient records to implement changes

3.5 Plan and deliver any required training for staff to implement changes made to the system

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, 1.3, 1.4, 2.1, 2.5, 2.7, 2.8, 3.1-3.5

  • Identifies and interprets relevant information and ideas within organisational texts

Writing

1.4, 2.1, 2.2, 2.3, 2.4, 2.7, 2.8, 3.1-3.5

  • Creates and maintains records using required words and codes
  • Prepares documentations for others using words and style appropriate to audience and context

Oral Communication

1.2, 1.4, 2.1, 2.2, 2.3, 2.6, 3.2, 3.4, 3.5

  • Communicates with relevant personnel and uses everyday language to train or supervise staff
  • Asks questions and listens for relevant information in oral texts

Navigate the world of work

1.1, 1.3, 2.6

  • Identifies and works according to roles and responsibilities, policies and procedures
  • Ensures own and others behaviour is consistent with the expected policies, procedures and responsibilities related to privacy, confidentiality and security in a medical environment

Interact with others

1.2, 1.4, 2.1, 2.2, 2.3, 3.2, 3.4, 3.5

  • Collaborates with relevant personnel to ensure understanding of the records system
  • Selects and uses appropriate communication practices when providing training or feedback to others

Get the work done

1.1-1.4, 2.1-2.5, 2.8, 3.1-3.5

  • Plans and organises own and others' tasks to ensure work is completed according to legislative and organisational requirements
  • Uses analytical processes to determine opportunities for improvements to processes

Unit Mapping Information

Code and title 

current version 

Code and title 

previous version 

Comments 

Equivalence status 

BSBMED401 Manage patient record-keeping system

BSBMED401B Manage patient recordkeeping system

Updated to meet Standards for Training Packages

Equivalent unit

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.education.gov.au/Pages/TrainingDocs.aspx?q=11ef6853-ceed-4ba7-9d87-4da407e23c10

 

Assessment requirements

Modification History

Release 

Comments 

Release 1

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

Performance Evidence

Evidence of the ability to:

  • manage a patient recordkeeping system and supervise its use
  • document how records have been accessed and archived by staff or self in accordance with organisational and legislative requirements
  • provide activities to others that support correct use of a patient record system.

Note: if a specific volume or frequency is not stated, then evidence must be provided at least once.

Knowledge Evidence

To complete the unit requirements safely and effectively, the individual must:

  • outline relevant legislation, regulations, standards and codes of practice for maintaining records in a medical environment
  • explain enterprise policies and procedures related to:
  • patient recordkeeping including archiving and records transfer
  • privacy and confidentiality
  • access to records
  • describe filing systems and record management processes
  • explain how medical coding is used to help access and maintain patient records.

Assessment Conditions

Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the medical services administration field of work and include access to:

  • office equipment and resources
  • documents and records
  • a records system
  • documented procedures
  • case studies and, where possible, real situations.

Assessors must satisfy NVR/AQTF assessor requirements.

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.education.gov.au/Pages/TrainingDocs.aspx?q=11ef6853-ceed-4ba7-9d87-4da407e23c10

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