Elements and Performance Criteria
- Identify and evaluate clinical data from simple medical records
- Identify the principal diagnosis and principal procedure when coding from a simple medical record
- Identify additional diagnosis and procedures when coding from a simple medical record
- Refer any issues concerning clarity and accuracy of the clinical data to the appropriate person
- Evaluate the relevance of other health conditions and factors affecting the patient to establish the primary diagnosis
- Establish the appropriate level of detail of clinical data to meet standards
- Record, enter, edit and maintain a client information system of coded data (disease index)
- Identify the correct clinical data within appropriate timeframes
- Assign codes to clinical data
- Assign complete and accurate ICD-10-AM disease and procedures codes abstracted from simple medical records
- Apply Australian National Coding Standards where appropriate, to ensure the correct assignment of codes
- Establish and record the correct sequence and order of codes related to a single episode in accordance with standards
- Record data clearly, accurately and completely
- Maintain confidentiality at all times
- Enter the coded data accurately into the client appropriate system
- Complete the process of assigning the correct codes from clinical data within appropriate timeframes