Unit of competency Outline
Date retreived
23/07/2026 7:03 AM AWST
23/07/2026 7:03 AM 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.
Produce coded clinical data
Produce coded clinical data
Unit of competency
National Code
HLTCC301B
HLTCC301B
State Code
D5816
D5816
TGA Status
Replaced
Replaced
DTWD Status
Replaced
Replaced
State Implementation and Classification
Approved Date
30/07/2012
Field of Education
080905 - Practical Computing Skills
Original Release Date
30/07/2012
Nominal Hours
20
Description
DescriptorThis unit of competency describes the skills and knowledge required to accurately extract the correct clinical data from simple medical records
Notes
Elements and Performance Criteria
1. Identify and evaluate clinical data from simple medical records
- 1.1 Identify the principal diagnosis and principal procedure when coding from a simple medical record
- 1.2 Identify additional diagnosis and procedures when coding from a simple medical record
- 1.3 Refer any issues concerning clarity and accuracy of the clinical data to the appropriate person
- 1.4 Evaluate the relevance of other health conditions and factors affecting the patient to establish the primary diagnosis
- 1.5. Establish the appropriate level of detail of clinical data to meet standards
- 1.6 Record, enter, edit and maintain a client information system of coded data (disease index)
- 1.7 Identify the correct clinical data within appropriate timeframes
2. Assign codes to clinical data
- 2.1 Assign complete and accurate ICD-10-AM disease and procedures codes abstracted from simple medical records
- 2.2 Apply Australian National Coding Standards where appropriate, to ensure the correct assignment of codes
- 2.3 Establish and record the correct sequence and order of codes related to a single episode in accordance with standards
- 2.4 Record data clearly, accurately and completely
- 2.5 Maintain confidentiality at all times
- 2.6 Enter the coded data accurately into the client appropriate system
- 2.7 Complete the process of assigning the correct codes from clinical data within appropriate timeframes
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. Add any 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.
Simple medical records may include
A medical record generated by an episode of care involving one of the following:
Day stay
Day surgery
Planned surgery
Simple medical problems in episodes of care not exceeding a length of stay (LOS) of three days
Diagnosis may include:
Diagnosis of:
congenital malformations and deformations
endocrine, nutrition and metabolic diseases
injuries and external causes of injuries
neoplasms
poisoning and external causes of poisoning
symptoms, signs and abnormal clinical findings
Diagnosis of diseases of the:
circulatory system
digestive system
ear and mastoid process
eye and adnexa
genitourinary system
musculoskeletal system
nervous system
respiratory system
skin and subcutaneous tissue
Diagnosis:
in pregnancy, childbirth and the puerperium
originating in the perinatal period
Clinical coding requirements may include:
Coding requirements of:
congenital malformations and deformations
endocrine, nutrition and metabolic diseases
injuries and external causes of injuries
neoplasms
poisoning and external causes of poisoning
symptoms, signs and abnormal clinical findings
Coding diseases of the:
circulatory system
digestive system
ear and mastoid process
eye and adnexa
genitourinary system
musculoskeletal system
nervous system
respiratory system
skin and subcutaneous tissue
Coding conditions:
in pregnancy, childbirth and the puerperium
originating in the perinatal period
Client information systems may include
Computerised systems
Manual systems
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any 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.
Simple medical records may include
A medical record generated by an episode of care involving one of the following:
Day stay
Day surgery
Planned surgery
Simple medical problems in episodes of care not exceeding a length of stay (LOS) of three days
Diagnosis may include:
Diagnosis of:
congenital malformations and deformations
endocrine, nutrition and metabolic diseases
injuries and external causes of injuries
neoplasms
poisoning and external causes of poisoning
symptoms, signs and abnormal clinical findings
Diagnosis of diseases of the:
circulatory system
digestive system
ear and mastoid process
eye and adnexa
genitourinary system
musculoskeletal system
nervous system
respiratory system
skin and subcutaneous tissue
Diagnosis:
in pregnancy, childbirth and the puerperium
originating in the perinatal period
Clinical coding requirements may include:
Coding requirements of:
congenital malformations and deformations
endocrine, nutrition and metabolic diseases
injuries and external causes of injuries
neoplasms
poisoning and external causes of poisoning
symptoms, signs and abnormal clinical findings
Coding diseases of the:
circulatory system
digestive system
ear and mastoid process
eye and adnexa
genitourinary system
musculoskeletal system
nervous system
respiratory system
skin and subcutaneous tissue
Coding conditions:
in pregnancy, childbirth and the puerperium
originating in the perinatal period
Client information systems may include
Computerised systems
Manual systems
EVIDENCE GUIDE
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
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 and/or Torres Strait Islander clients and communities
Context of and specific resources for assessment:
Relevant guidelines, standards and procedures
Resources essential for assessment include:
ICD-10-AM, ACHI and ACS and relevant local coding requirements
simple medical records
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
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 and/or Torres Strait Islander clients and communities
Context of and specific resources for assessment:
Relevant guidelines, standards and procedures
Resources essential for assessment include:
ICD-10-AM, ACHI and ACS and relevant local coding requirements
simple medical records
Replaces
| State Code | National Code | Title | Type |
|---|---|---|---|
| C9124 | HLTCC301A | Produce coded clinical data | Unit of competency |
Replaced By
| State Code | National Code | Title | Type |
|---|---|---|---|
| AVB14 | HLTADM005 | Produce coded clinical data | Unit of competency |
| State Code | National Code | Title | Type |
|---|---|---|---|
| J069 | HLT32912 | Certificate III in Health Administration | Qualification |
| D052 | HLT32907 | Certificate III in Health Administration | Qualification |