Unit of competency Outline

Date retreived
23/07/2026 12:30 AM AWST

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Interpret and navigate health care records

Interpret and navigate health care records

Unit of competency
National Code
HLTCCD002
State Code
ODI35
TGA Status
Current
DTWD Status
Approved
Current Release Number
2.00
Current Release Date
02/07/2021
View on TGA
State Implementation and Classification
Approved Date
29/10/2021
Field of Education
080313 - Public And Health Care Administration
Original Release Date
29/10/2021
Nominal Hours
55
Description
This unit describes the performance outcomes, skills and knowledge required to accurately interpret information in health care records to support accurate clinical coding of an episode of care.This unit applies to clinical coders who are responsible for extracting and interpreting patient clinical information for the purposes of clinical coding. Work may be performed as an individual or as part of a team under limited supervision.The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian standards and industry codes of practice.No occupational licensing, certification or specific legislative requirements apply to this unit at the time of publication.
Notes
Elements and Performance Criteria
1. Locate patient information.
  • 1.1. Select method for accessing patient information held in hard copy or electronic formats.
  • 1.2. Locate patient health care records using Patient Administration System (PAS).
  • 1.3. Access and manage patient health care records according to organisational policies and procedures for privacy and confidentiality.
2. Review content of patient health care records.
  • 2.1. Identify categories of information recorded in patient health care records taking into account structure and layout.
  • 2.2. Identify documentation flow in relation to the patient journey in a health care service provider setting.
  • 2.3. Identify mandatory data elements for admitted patient health care records that must be reported to the Commonwealth and State or Territory jurisdictions.
3. Analyse relationship between patient health care records and clinical coding.
  • 3.1. Analyse health care records to determine the reason for patient admission, surgery, interventions performed and conditions that arise during episode of care.
  • 3.2. Clarify absent and incomplete information according to organisational policies and procedures.
  • 3.3. Determine completeness of health care record information for clinical coding.
4. Maintain privacy and confidentiality of patient health care records.
  • 4.1. Discuss patient-related matters within confines of the facility and with appropriate personnel.
  • 4.2. Identify and meet legal and ethical responsibilities, including prompt disclosure of conflict of interest to supervisor when dealing with patient health care records.
  • 4.3. Seek advice and clarification from supervisor where potential confidentiality issues arise in dealings with patient health care records.
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