Unit of competency Outline

Date retreived
22/07/2026 1:10 PM AWST

Whilst all efforts are made to provide accurate and timely information from the relevant source/documentation, please be aware that the information supplied may not be the most current version. The accuracy of the detail has not been confirmed by the Department and therefore should not be relied upon without first confirming the contents.

Manage patient record keeping system

Manage patient record keeping system

Unit of competency
National Code
BSBMED401B
State Code
D0840
TGA Status
Replaced
DTWD Status
Replaced
Current Release Number
1.00
Current Release Date
10/03/2009
View on TGA
State Implementation and Classification
Approved Date
05/08/2014
Field of Education
080901 - Secretarial And Clerical Studies
Original Release Date
05/08/2014
Nominal Hours
40
Description
This unit describes the performance outcomes, skills and knowledge required to manage a patient record system within a medical environment and to supervise others. It covers clarifying roles and responsibilities, managing the operation of a patient records system, and reviewing and improving the system.No licensing, legislative, regulatory or certification requirements apply to this unit at the time of endorsement.
Notes
Elements and Performance Criteria
1. Clarify how patient records system operates
  • 1.1. Access policies and procedures for patient records
  • 1.2. Consult relevant personnel about how the system operates
  • 1.3. Determine roles and responsibilities for the system operations
  • 1.4. Communicate roles and responsibilities for system operations to relevant personnel
2. Manage operation of patient records system
  • 2.1. Supervise staff maintaining patient records
  • 2.2. Provide staff maintaining patient records with training as required
  • 2.3. Regularly consult staff using patient records about system efficacy
  • 2.4. Maintain integrity of patient records
  • 2.5. Maintain security of patient records
  • 2.6. Stress importance of confidentiality of patient records to all staff, including self, who handle or have access to patient files
  • 2.7. Provide authorisation of transfer of records from facility according to practice protocols
  • 2.8. Archive records as appropriate
3. Review and improve patient records system
  • 3.1. Monitor and review implementation of the system to identify improvements
  • 3.2. Make recommendations to relevant personnel for system improvements
  • 3.3. Implement approved recommendations
  • 3.4. Supervise staff maintaining patient records to implement changes
  • 3.5. Plan and deliver any required training for staff to implement changes made to the system
RANGE STATEMENT
The range statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Bold italicised wording, if used in the performance criteria, is detailed below. Essential operating conditions that may be present with training and assessment (depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts) may also be included.
Relevant personnel may include:
chief executive officer, director or manager of the business
external bodies including peak industry organisations
health professionals using the system
partners in the business
reception staff
staff managing patient records
System may include:
software and hardware-based records management systems
print-based records management systems
Supervising staff may include:
coaching/mentoring
documenting procedures and processes
formal training
Authorisation of transfer of records may occur in relation to:
organisational policy
organisational procedure
relevant laws
EVIDENCE GUIDE
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:
managing a patient record keeping system over a significant period
documenting how records have been accessed and archived by staff or self
demonstrating how records have been provided to support relevant medical activities
knowledge of relevant legislation from all levels of government.
Context of and specific resources for assessment
Assessment must ensure:
access to an actual workplace or simulated environment
access to office equipment and resources
examples of documents and records for archiving
access to records system
documented procedures.
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 on-the-job performance by the candidate
review of archived records
analysis of responses to case studies and scenarios
demonstration of techniques
observation of presentations
oral or written questioning to assess knowledge of filing systems and record management processes
observation of performance in role plays.
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.
Replaces
State Code National Code Title Type
C7001 BSBMED401A Manage patient record-keeping system Unit of competency
Replaced By
State Code National Code Title Type
AUJ06 BSBMED401 Manage patient recordkeeping system Unit of competency