Google Links

Follow the links below to find material targeted to the unit's elements, performance criteria, required skills and knowledge

Elements and Performance Criteria

1. Identify and clarify own role and procedures for patient recordkeeping
   • Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual
   • Access documented procedures for patient recordkeeping system and read for understanding
   • Seek clarification with relevant personnel of unclear or ambiguous procedures
2. Access patient records
   • Gain access to patient records to facilitate patient visit
   • Check currency and accuracy of patient demographic and personal details
   • Create new records according to enterprise protocols
   • Check records following patient visits, for practitioners’ instructions related to follow-up action
   • Store patient files following organisational policy and procedures
3. Help maintain records
   • Make checks of patient files
   • Carry out archiving of patient files as required
   • Transfer patient files to another health facility upon appropriate request for patient information
4. Monitor and review own role
   • Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices
   • Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records

Performance Evidence

Evidence of the ability to:

use a recordkeeping system to create, access, store and maintain accurate records, according to organisational and legislative requirements

identify and recommend improvements to recordkeeping system or own work practices

communicate with relevant people about patient records.

Note: if a specific volume or frequency is not stated, then evidence must be provided at least once.

---

Knowledge Evidence

To complete the unit requirements safely and effectively, the individual must:

outline relevant legislation, standards and/or codes of practice that affect patient recordkeeping

explain workplace policies and procedures related to patient recordkeeping, including privacy and confidentiality

describe the process used to set up and maintain a patient record

explain how coding systems help users to access and to maintain patient records.

---