Unit of competency details
HLTADM005 - Produce coded clinical data (Release 1)
Summary
Usage recommendation:
Superseded
Releases:
| 1 1 (this release) |
06/Aug/2015 |
Companion volumes:
Unit of competency
Assessment requirements
Training packages that include this unit
Qualifications that include this unit
Skill sets that include this unit
Classifications
Classification history
| ASCED Module/Unit of Competency Field of Education Identifier | 080905 | Practical Computing Skills | 02/Nov/2015 | |
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Unit of competency
Modification History
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Release
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Comments
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Release 1
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This version was released in HLT Health Training Package release 2.0 and meets the requirements of the 2012 Standards for Training Packages.
Minimal changes to the elements and performance criteria. New evidence requirements for assessment, including volume and frequency.
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Application
This unit describes the skills and knowledge required to extract the correct clinical data from simple medical records. A simple medical record is defined as a medical record generated by an episode of care involving day stay, day surgery, planned surgery or simple medical problems with an average length of stay.
This unit applies to clinical coders.
The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.
Elements and Performance Criteria
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ELEMENT
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PERFORMANCE CRITERIA
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Elements define the essential outcomes
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Performance criteria describe the performance needed to demonstrate achievement of the element.
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1. Identify and evaluate clinical data from simple medical records
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1.1 Identify the principal diagnosis and principal procedure for an admission when coding from a simple medical record
1.2 Identify additional diagnosis and procedures when coding from a simple medical record with specialties
1.3 Refer any issues concerning clarity and accuracy of the clinical data to the appropriate person
1.4 Evaluate the relevance of other health conditions and factors affecting the patient to establish the principal diagnosis
1.5. Establish the appropriate level of detail of clinical data to meet standards
1.6 Record, enter, edit and maintain a client information system of coded data (disease index)
1.7 Identify the correct clinical data within appropriate timeframes
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2. Assign codes to clinical data
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2.1 Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease and procedures codesabstracted from simple medical records
2.2 Apply Australian coding standards (ACS) where appropriate, to ensure the correct assignment of codes when coding simple medical records for specialities
2.3 Establish and record the correct sequence and order of codes related to a single episode in accordance with standards
2.4 Record data clearly, accurately and completely
2.5 Enter the coded data accurately into the client system appropriate
2.6 Complete the process of assigning the correct codes from clinical data within appropriate timeframes
2.7 Maintain confidentiality of medical records and client information at all times
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Foundation Skills
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The Foundation Skills describe those required skills (language, literacy, numeracy and employment skills) that are essential to performance.
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Foundation skills essential to performance are explicit in the performance criteria of this unit of competency.
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Unit Mapping Information
No equivalent unit.
Links
Companion Volume implementation guides are found in VETNet - https://vetnet.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705
Assessment requirements
Modification History
|
Release
|
Comments
|
|
Release 1
|
This version was released in HLT Health Training Package release 2.0 and meets the requirements of the 2012 Standards for Training Packages.
Minimal changes to the elements and performance criteria. New evidence requirements for assessment, including volume and frequency.
|
Performance Evidence
The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:
- used current coding manuals and standards to produce accurate and complete coded clinical data from simple medical records for at least 10 different types of patients , including those with:
- differing length of stay
- both acute and chronic forms of a disease or condition
- different service category types
- with disease or condition in different contexts (co-existing with multiple comorbidities and complications)
Knowledge Evidence
The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:
- the broad health industry context for clinical coding
- coding factors influencing health status
- definition of a clinical coder and clinical coding, and the purpose of coded data
- current codes of practice and guidelines in relation to clinical coding, including professional ethics
- Australian and relevant state/territory clinical coding standards and protocols
- the way rules and conventions are applied to clinical data to achieve correct clinical codes
- sequencing protocols for clinical coding, including those for principle and additional diagnoses
- timescales within which clinical coding must take place
- classifications and nomenclature used to achieve accurate clinical coding
- clinical data indexing, storage and mapping from clinical terms of classifications
- comprehensive knowledge of medical terminology and body systems
- coding classifications relating to:
- congenital malformations and deformations
- endocrine, nutrition and metabolic diseases
- injuries and external causes of injuries
- neoplasms
- infectious diseases
- blood disorders
- poisoning and external causes of poisoning
- symptoms, signs and abnormal clinical findings
- coding classifications for diseases of:
- circulatory system
- digestive and hepatobiliary system
- ear and mastoid process
- eye and adnexa
- nose and mouth
- genitourinary system
- musculoskeletal system
- nervous system
- respiratory system
- skin and subcutaneous tissue
- relating to drugs, alcohol and mental health
- in pregnancy, childbirth and the puerperium
- originating in the perinatal period
Assessment Conditions
Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit:
- use of suitable facilities, equipment and resources, including:
- real medical records, either electronic or paper based
- ICD-10-AM, Australian classification of health interventions (ACHI) and ACS coding manuals
- modelling of industry operating conditions, including:
- presence of time constraints for coding activities
- integration of situations requiring problem solving
Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.
Links
Companion Volume implementation guides are found in VETNet - https://vetnet.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705
