Required skills

planning and organising skills to access and maintain records

communication skills to receive and clarify instructions

analysis skills to identify and address gaps in own knowledge

Required knowledge

occupational health and safety OHS for example

manual lifting of materials

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

antidiscrimination legislation

ethical principles

privacy laws

Freedom of Information Act

specific legislation related to patient records

organisation policies and procedures related to

patient record keeping

privacy and confidentiality

access to records

filing systems and record management processes

medical coding as required to access and maintain patient records

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

using record and file management systems to ensure organisation and accuracy of practice files

communicating with internal staff and other external health care providers to maintain accuracy of patient data

applying knowledge of the healthcare system and practice policies and procedures to ensure accessibility of records

Context of and specific resources for assessment

Assessment must ensure

access to records system

documented procedures

access to an actual workplace or simulated environment

access to office equipment and resources

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 onthejob performance by the candidate

review of new records created

analysis of responses to case studies and scenarios

demonstration of techniques

observation of presentations

oral or written questioning to assess knowledge of workplace emergencies risks and hazards

observation of performance in role plays

assessment of archived patient files

assessment of recommendations made for improvements to the procedures and processes for maintaining patient records

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

System may include:

Relevant personnel may include:

Practitioners' instructions may include:

Checks of patient files may include:

Archiving may include:

Appropriate request for patient information refers to: