Modification History
Not applicable.
Unit Descriptor
Unit descriptor |
This unit describes the performance outcomes, skills and knowledge required to manage a patient record system within a medical environment and to supervise others. It covers clarifying roles and responsibilities, managing the operation of a patient records system, and reviewing and improving the system. No licensing, legislative, regulatory or certification requirements apply to this unit at the time of endorsement. |
Application of the Unit
Application of the unit |
This unit applies to individuals managing an existing record keeping 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 facility. The unit does not cover the design of a new system but does cover reviews and improvements to an existing system. BSBMED303B Maintain patient records, covers the day to day implementation of the system. |
Licensing/Regulatory Information
Not applicable.
Pre-Requisites
Prerequisite units |
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Employability Skills Information
Employability skills |
This unit contains employability skills. |
Elements and Performance Criteria Pre-Content
Elements describe the essential outcomes of a unit of competency. |
Performance criteria describe the performance needed to demonstrate achievement of the element. Where bold italicised text is used, further information is detailed in the required skills and knowledge section and the range statement. Assessment of performance is to be consistent with the evidence guide. |
Elements and Performance Criteria
ELEMENT |
PERFORMANCE CRITERIA |
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, including self, who handle or have access to patient files 2.7. Provide authorisation of transfer of records from facility according to practice protocols 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 |
Required Skills and Knowledge
REQUIRED SKILLS AND KNOWLEDGE |
This section describes the skills and knowledge required for this unit. |
Required skills |
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Required knowledge |
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Evidence Guide
EVIDENCE GUIDE |
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The Evidence Guide provides advice on assessment and must be read in conjunction with the performance criteria, required skills and knowledge, range statement and the Assessment Guidelines for the Training Package. |
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Overview of assessment |
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Critical aspects for assessment and evidence required to demonstrate competency in this unit |
Evidence of the following is essential:
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Context of and specific resources for assessment |
Assessment must ensure:
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Method of assessment |
A range of assessment methods should be used to assess practical skills and knowledge. The following examples are appropriate for this unit:
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Guidance information for assessment |
Holistic assessment with other units relevant to the industry sector, workplace and job role is recommended, for example:
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Range Statement
RANGE STATEMENT |
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The range statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Bold italicised wording, if used in the performance criteria, is detailed below. Essential operating conditions that may be present with training and assessment (depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts) may also be included. |
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Relevant personnel may include: |
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System may include: |
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Supervising staff may include: |
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Authorisation of transfer of records may occur in relation to: |
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Unit Sector(s)
Unit sector |
Competency field
Competency field |
Administration - Medical Services Administration |
Co-requisite units
Co-requisite units |
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