BSBMED303 Maintain patient records

Release: 1

BSBMED303 Maintain patient records

Modification History

Release	Comments
Release 1	This version first released with BSB Business Services Training Package Version 1.0.

Application

This unit describes the skills and knowledge required to maintain patient records within an existing medical records management system, under the supervision of a senior receptionist or practice manager.

It applies to individuals who apply a broad range of competencies in various medical administration contexts. They are skilled operators who are expected to exercise discretion and judgement in accessing and maintaining patient records while fully respecting patient privacy and the confidentiality of their details.

No licensing, legislative, regulatory or certification requirements apply to this unit at the time of publication.

Unit Sector

Administration – Medical Services Administration

Elements and Performance Criteria

ELEMENT	PERFORMANCE CRITERIA
Elements describe the essential outcomes.	Performance criteria describe the performance needed to demonstrate achievement of the element.
1. Identify and clarify own role and procedures for patient recordkeeping	1.1 Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual 1.2 Access documented procedures for patient recordkeeping system and read for understanding 1.3 Seek clarification with relevant personnel of unclear or ambiguous procedures
2. Access patient records	2.1 Gain access to patient records to facilitate patient visit 2.2 Check currency and accuracy of patient demographic and personal details 2.3 Create new records according to enterprise protocols 2.4 Check records following patient visits, for practitioners’ instructions related to follow-up action 2.5 Store patient files following organisational policy and procedures
3. Help maintain records	3.1 Make checks of patient files 3.2 Carry out archiving of patient files as required 3.3 Transfer patient files to another health facility upon appropriate request for patient information
4. Monitor and review own role	4.1 Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices 4.2 Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records

Foundation Skills

This section describes language, literacy, numeracy and employment skills incorporated in the performance criteria that are required for competent performance.

Skill	Performance Criteria	Description
Reading	1.1, 1.2, 1.3, 2.2, 2.3, 2.4, 2.5, 3.1, 3.2, 4.2	Recognises and interprets a range of everyday workplace information including organisational protocols and medical data
Writing	2.3, 3.2, 3.3, 4.2	Creates and maintains records according to organisational requirements Documents recommendations for improved processes using simple vocabulary and required structure
Oral Communication	1.1, 1.3, 4.2	Uses specific vocabulary and active listening and questioning techniques to confirm understanding
Navigate the world of work	1.1, 2.3, 2.5	Identifies and works within own roles and responsibilities according to organisational procedures and protocols
Interact with others	1.1, 1.3, 4.2	Selects the appropriate form, channel and mode of communication for a specific purpose related to own work Collaborates with others to achieve results in immediate work context
Get the work done	1.1, 2.1, 2.5, 3.1-3.3, 4.1, 4.2	Plans and sequences workload to ensure tasks are completed accurately and in a timely manner Uses analytical skills to determine recommendations for improvement to established processes and procedures

Unit Mapping Information

Code and title current version	Code and title previous version	Comments	Equivalence status
BSBMED303 Maintain patient records	BSBMED303B Maintain patient records	Updated to meet Standards for Training Packages	Equivalent unit

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.gov.au/Pages/TrainingDocs.aspx?q=11ef6853-ceed-4ba7-9d87-4da407e23c10