BSBMED401B Manage patient record keeping system

Revision Number: 1

BSBMED401B Manage patient record keeping system

Modification History

Not applicable.

Unit Descriptor

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

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.

Licensing/Regulatory Information

Not applicable.

Pre-Requisites

Prerequisite units

Employability Skills Information

Employability skills	This unit contains employability skills.

Elements and Performance Criteria Pre-Content

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.

Elements and Performance Criteria

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

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

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

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(s)

Unit sector

Competency field

Competency field	Administration - Medical Services Administration

Co-requisite units

Co-requisite units