This describes the essential skills and knowledge and their level required for this unit

Essential knowledge

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit manage the task and manage contingencies in the context of the identified work role

This includes knowledge of

Advanced knowledge of Australian and relevant StateTerritory clinical coding conventions standards and practices

Appropriate legislation

Application of professional ethics in clinical coding

Classifications and nomenclature used to achieve accurate clinical coding

Clinical data indexing storage and mapping from clinical terms of classifications

Coding factors influencing health status

Coding relating to

circulatory system

dermatology and plastic surgery

drugs alcohol and mental health

ear nose throat and dental

endocrine system

gastrointestinal and hepatobiliary systems

genitourinary system

haemotology

immunology and infectious diseases

neonatology and paediatrics

neurology and neurosurgery

oncology

ophthalmology

orthopaedics

poisoning adverse reactions postprocedural complications and sequelae of injuries poisoning and other external causes

pregnancy and childbirth

respiratory system

trauma

Comprehensive knowledge of medical terminology and body systems

Current codes of practice and guidelines in relation to clinical coding

Sequencing of codes and primary diagnosis

Sequencing protocols for clinical coding

Sources of information relating to changes to clinical coding requirements

Timescales within which clinical coding must take place

Essential skills

It is critical that the candidate demonstrate the ability to effectively do the task outlined in elements and performance criteria of this unit manage the task and manage contingencies in the context of the identified work role

This includes the ability to

Analyse a varied and highly complex casemix from a range of specialties to produce coded clinical data

Apply Australian National Coding Standards to code highly complex medical records in an extensive casemix

Complete coding of an average of four highly complex medical records per hour

Enter data to at least accuracy from highly complex medical records

Identify coding issues and conduct research using appropriate materialsresources and or clinical input to generate solutions

Identify sequencing requirements in varied and complex medical records

Identify interpret and apply necessary amendments to data collection and coding activities

Research and secure information to manage coding questions and complications

Use appropriate resources to assist with highly complex clinical coding requirements

Use manual or an interfaced computerised coding system to submit data or disease index

The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria Required Skills and Knowledge the Range Statement and the Assessment Guidelines for this Training Package

Critical aspects for assessment and evidence required to demonstrate this competency unit

The individual being assessed must provide evidence of specified essential knowledge as well as skills

Consistency of performance should be demonstrated over the required range of situations relevant to the workplace

This unit must be assessed after successful achievement of the identified prerequisite unit and extensive clinical coding work experience

Access and equity considerations

All workers in the health industry should be aware of access and equity issues in relation to their own area of work

All workers should develop their ability to work in a culturally diverse environment

In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities workers should be aware of cultural historical and current issues impacting on health of Aboriginal and Torres Strait Islander people

Assessors and trainers must take into account relevant access and equity issues in particular relating to factors impacting on health of Aboriginal andor Torres Strait Islander clients and communities

Context of and specific resources for assessment

Resources essential for assessment include

Relevant guidelines standards and procedures

ICDAM ACHI and ACS and relevant local coding requirements

a range of medical records reflecting a varied and highly complex casemix from range of specialties

appropriate resource materials

Highly complex medical records refer to:

Appropriate resources may include:

Disease and procedure codes may include:

Client information systems may include: