Unit of competency
Modification History
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Release |
Comments |
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Release 2 |
Release 2 HLTCCD002 Interpret and navigate health care records supersedes and is equivalent to Release 1 HLTCCD002 Interpret and navigate health care records. Updated: Mapping details and minor corrections |
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Release 1 |
HLTCCD002 Interpret and navigate health care records no equivalent unit. |
Application
This unit describes the performance outcomes, skills and knowledge required to accurately interpret information in health care records to support accurate clinical coding of an episode of care.
This unit applies to clinical coders who are responsible for extracting and interpreting patient clinical information for the purposes of clinical coding. Work may be performed as an individual or as part of a team under limited supervision.
The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian standards and industry codes of practice.
No occupational licensing, certification or specific legislative requirements apply to this unit at the time of publication.
Pre-requisite Unit
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Unit code |
Unit title |
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HLTCCD001 |
Apply an understanding of the health care system to clinical coding practice. |
Competency Field
Clinical Coding
Unit Sector
Health Administration
Elements and Performance Criteria
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ELEMENTS |
PERFORMANCE CRITERIA |
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Elements describe the essential outcomes |
Performance criteria describe the performance needed to demonstrate achievement of the element. |
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1. Locate patient information. |
1.1. Select method for accessing patient information held in hard copy or electronic formats. 1.2. Locate patient health care records using Patient Administration System (PAS). 1.3. Access and manage patient health care records according to organisational policies and procedures for privacy and confidentiality. |
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2. Review content of patient health care records. |
2.1. Identify categories of information recorded in patient health care records taking into account structure and layout. 2.2. Identify documentation flow in relation to the patient journey in a health care service provider setting. 2.3. Identify mandatory data elements for admitted patient health care records that must be reported to the Commonwealth and State or Territory jurisdictions. |
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3. Analyse relationship between patient health care records and clinical coding. |
3.1. Analyse health care records to determine the reason for patient admission, surgery, interventions performed and conditions that arise during episode of care. 3.2. Clarify absent and incomplete information according to organisational policies and procedures. 3.3. Determine completeness of health care record information for clinical coding. |
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4. Maintain privacy and confidentiality of patient health care records. |
4.1. Discuss patient-related matters within confines of the facility and with appropriate personnel. 4.2. Identify and meet legal and ethical responsibilities, including prompt disclosure of conflict of interest to supervisor when dealing with patient health care records. 4.3. Seek advice and clarification from supervisor where potential confidentiality issues arise in dealings with patient health care records. |
Foundation Skills
Foundation skills essential to performance are explicit in the performance criteria of this unit of competency.
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
