Unit of competency details

Descriptor 

This unit of competency describes the skills and knowledge required to undertake coding of moderately complex discharge summaries, medical reports and medical records, including the selection of the primary diagnosis and sequencing of other diagnoses for coding

Application 

Work performed requires a range of well developed skills where discretion and judgement is required and individuals will take responsibility for their own outputs

Pre-requisite unit 

This unit must be assessed after successful achievement of pre-requisite:

• HLTCC301B Produce coded clinical data

Employability Skills 

This unit contains Employability Skills

Elements define the essential outcomes of a unit of competency.

The Performance Criteria specify the level of performance required to demonstrate achievement of the Element. Terms in italics are elaborated in the Range Statement.

ELEMENT 

PERFORMANCE CRITERIA 

1. Abstract clinical data from moderately complex medical records 

1.1 Interpret and apply the Australian National Coding Standards to identify clinical data from moderately complex discharge summaries, medical reports and medical records

1.2 Select appropriate conditions/diseases and procedures for coding from moderately complex medical records

1.3 Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records

1.4 Identify additional diagnoses and procedures

1.5 Establish the correct sequencing of diagnoses and procedures

2. Assign codes relating to moderately complex medical records

2.1 Apply Australian National Coding Standards where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties

2.2 Assign complete and accurate ICD-10-AM disease and ACHI procedure codes 

2.3 Utilise resources  where appropriate to assist in making coding decisions

2.4 Recognise problems relating to privacy and confidentiality of client information

2.5 Maintain confidentiality of medical records and client information at all times

2.6 Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes

2.7 Meet occupational health and safety duty of care requirements

3. Maintain clinical coding records

3.1 Record, enter, edit and maintain a client information system  of coded data (disease index)

3.2 Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation

3.3 Make amendments to data collection and coding activities in line with organisation requirements

3.4 Maintain and update own knowledge and skills to ensure that amendments are addressed as required

REQUIRED SKILLS AND KNOWLEDGE 

This describes the essential skills and knowledge and their level required for this unit.

Essential knowledge :

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes knowledge of:

• Australian and relevant State/Territory clinical coding standards and protocols
• Appropriate legislation
• Definition of a clinical coder and clinical coding, and the purpose of coded data
• Professional ethics in clinical coding
• Classifications and nomenclature used to achieve accurate clinical coding
• Clinical data indexing, storage and mapping from clinical terms of classifications
• Coding diseases and procedures with ICD-10-AM, ACHI and ACS coding manuals
• Coding factors influencing health status
• Coding relating to:

• infectious and blood diseases
• mental health
• endocrine and musculoskeletal diseases
• injuries and poisonings
• neoplasms, digestive and skin diseases
• respiratory and circulatory diseases
• nervous system, eye, ear, nose and mouth diseases
• genitourinary, pregnancy, childbirth, the puerperium, the perinatal period and congenital conditions

• Comprehensive knowledge of medical terminology and body systems
• Current codes of practice and guidelines in relation to clinical coding
• Sequencing of primary and additional diagnoses
• Sequencing protocols for clinical coding
• Sources of information relating to changes to clinical coding requirements
• Timeframes for completing clinical coding

Essential skills :

It is critical that the candidate demonstrate the ability to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes the ability to:

• Analyse moderately complex medical records from a range of specialties to produce coded clinical data
• Apply Australian National Coding Standards to code moderately complex medical records
• Complete coding of an average of four moderately complex medical records per hour
• Enter data to at least 80%accuracy from moderately complex medical records
• Identify necessary amendments to data collection and coding activities
• Identify sequencing requirements in moderately complex medical records
• Use appropriate resources to assist with moderately complex clinical coding requirements
• Use ICD-10-AM, ACHI and ACS coding manuals
• Use manual or an interfaced computerised coding system to submit data or disease index

EVIDENCE GUIDE 

The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.

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

• The individual being assessed must provide evidence of specified essential knowledge as well as skills
• Consistency of performance should be demonstrated over the required range of situations relevant to the workplace

Access and equity considerations :

• All workers in the health industry should be aware of access and equity issues in relation to their own area of work
• All workers should develop their ability to work in a culturally diverse environment
• In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people
• Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities

Context of and specific resources for assessment :

• Assessment must be completed in the workplace
• Relevant guidelines, standards and procedures
• Resources essential for assessment include:

• ICD-10-AM, ACHI and ACS and relevant local coding requirements
• a range of complex medical records
• resources material

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. Add any 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.

Moderately complex medical records refer to :

• Medical records resulting from an episode of care generally seen in health care facilities ranging from large to small size hospitals (AIHW National Hospital Peer Group Classifications A1-D1)
• Medical information may be obtained from:

• discharge summaries
• medical reports
• medical records

Resources may include :

• MIMS
• Medical abbreviations dictionary

Disease and procedure codes may include :

• Coding for:

• endocrine and musculoskeletal diseases
• genitourinary, pregnancy, childbirth, the puerperium, the perinatal period and congenital conditions
• infectious and blood diseases
• injuries and poisonings
• mental health
• neoplasms, digestive and skin diseases
• nervous system, eye, ear, nose and mouth diseases
• respiratory and circulatory diseases

Client information systems may include :

• Computerised systems
• Manual systems