Unit of competency details

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 

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.

Prerequisite units 

Employability skills 

This unit contains employability skills.

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.

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 

This section describes the skills and knowledge required for this unit.

Required skills 

• management skills to supervise staff
• analysis skills to continuously improve procedures through reviewing, and identifying and implementing improvements.

Required knowledge 

• occupational health and safety (OHS), for example:

• manual lifting
• ergonomics associated with using computers and own work station

• relevant legislation from all levels of government that affects business operations, codes of practice and national standards, such as:

• anti-discrimination legislation
• consumer laws including appropriate state legislation
• ethical principles
• privacy laws
• statutory regulations for records
• specific legislation related to patient records

• enterprise policies and procedures related to:

• patient record keeping including archiving and records transfer
• privacy and confidentiality
• access to records

• filing systems and record management processes
• medical coding as required to access and maintain patient records.

EVIDENCE GUIDE 

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.

Overview of assessment 

Critical aspects for assessment and evidence required to demonstrate competency in this unit 

Evidence of the following is essential:

• managing a patient record keeping system over a significant period
• documenting how records have been accessed and archived by staff or self
• demonstrating how records have been provided to support relevant medical activities
• knowledge of relevant legislation from all levels of government.

Context of and specific resources for assessment 

Assessment must ensure:

• access to an actual workplace or simulated environment
• access to office equipment and resources
• examples of documents and records for archiving
• access to records system
• documented procedures.

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:

• direct questioning combined with review of portfolios of evidence and third party workplace reports of on-the-job performance by the candidate
• review of archived records
• analysis of responses to case studies and scenarios
• demonstration of techniques
• observation of presentations
• oral or written questioning to assess knowledge of filing systems and record management processes
• observation of performance in role plays.

Guidance information for assessment 

Holistic assessment with other units relevant to the industry sector, workplace and job role is recommended, for example:

• other general administration or medical services administration units.

RANGE STATEMENT 

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.

Relevant personnel  may include:

• chief executive officer, director or manager of the business
• external bodies including peak industry organisations
• health professionals using the system
• partners in the business
• reception staff
• staff managing patient records

System  may include:

• software and hardware-based records management systems
• print-based records management systems

Supervising  staff may include:

• coaching/mentoring
• documenting procedures and processes
• formal training

Authorisation of transfer of records  may occur in relation to:

• organisational policy
• organisational procedure
• relevant laws

Unit sector 

Competency field 

Administration - Medical Services Administration

Co-requisite units