Unit of competency Outline
Date retreived
23/07/2026 5:50 AM AWST
23/07/2026 5:50 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.
Maintain patient records
Maintain patient records
Unit of competency
National Code
BSBMED303B
BSBMED303B
State Code
D0837
D0837
TGA Status
Replaced
Replaced
DTWD Status
Replaced
Replaced
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 maintain patient records within an existing medical records management system, under supervision.No licensing, legislative, regulatory or certification requirements apply to this unit at the time of endorsement.
Notes
Elements and Performance Criteria
1. Identify and clarify own role and procedures for patient record keeping
- 1.1. Determine own role and responsibilities within patient record keeping system through consultation with relevant personnel or via organisational policy and procedures manual
- 1.2. Access documented procedures for patient record keeping system and read for understanding
- 1.3. Seek clarification with relevant personnel of unclear or ambiguous procedures
2. Access patient records
- 2.1. Gain access to patient records to facilitate patient visit
- 2.2. Check currency and accuracy of patient demographic and personal details
- 2.3. Create new records according to enterprise protocols
- 2.4. Check records following patient visits, for practitioners' instructions related to follow-up action
- 2.5. Store patient files following organisational policy and procedures
3. Help maintain records
- 3.1. Make checks of patient files
- 3.2. Carry out archiving of patient files as required
- 3.3. Transfer patient files to another health facility upon appropriate request for patient information
4. Monitor and review own role
- 4.1. Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices
- 4.2. Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records
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.
System may include:
print-based records management systems
software and hardware-based records management systems
Relevant personnel may include:
administrative manager
health professionals
manager of facility
own supervisor
partners in business
Practitioners' instructions may include:
filing documents in records
making further appointments with health professionals within the facility
referral to another health professional
request for a letter of referral to be prepared
Checks of patient files may include:
checking on a pre-determined cycle
checking on specified dates
ensuring files are neat, tidy and correct
ensuring files are stored in correct order (alphabetical, numerical, alphanumeric)
Archiving may include:
archiving on direction and under supervision
file storage using appropriate archiving options such as boxes, external storage facility, electronic scanning and imaging
identification of files for archiving
removal of files from system
Appropriate request for patient information refers to:
legitimate request for patient information agreed to by patient and for purposes of furthering treatment regime with another health facility and within legislative requirements including:
approval by relevant health practitioner
Freedom of Information Act
organisational policy and procedures
Privacy Act
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.
System may include:
print-based records management systems
software and hardware-based records management systems
Relevant personnel may include:
administrative manager
health professionals
manager of facility
own supervisor
partners in business
Practitioners' instructions may include:
filing documents in records
making further appointments with health professionals within the facility
referral to another health professional
request for a letter of referral to be prepared
Checks of patient files may include:
checking on a pre-determined cycle
checking on specified dates
ensuring files are neat, tidy and correct
ensuring files are stored in correct order (alphabetical, numerical, alphanumeric)
Archiving may include:
archiving on direction and under supervision
file storage using appropriate archiving options such as boxes, external storage facility, electronic scanning and imaging
identification of files for archiving
removal of files from system
Appropriate request for patient information refers to:
legitimate request for patient information agreed to by patient and for purposes of furthering treatment regime with another health facility and within legislative requirements including:
approval by relevant health practitioner
Freedom of Information Act
organisational policy and procedures
Privacy Act
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:
using record and file management systems to ensure organisation and accuracy of practice files
communicating with internal staff and other external health care providers to maintain accuracy of patient data
applying knowledge of the healthcare system, and practice policies and procedures to ensure accessibility of records.
Context of and specific resources for assessment
Assessment must ensure:
access to records system
documented procedures
access to an actual workplace or simulated environment
access to office equipment and resources.
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 new records created
analysis of responses to case studies and scenarios
demonstration of techniques
observation of presentations
oral or written questioning to assess knowledge of workplace emergencies, risks and hazards
observation of performance in role plays
assessment of archived patient files
assessment of recommendations made for improvements to the procedures and processes for maintaining patient records.
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.
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:
using record and file management systems to ensure organisation and accuracy of practice files
communicating with internal staff and other external health care providers to maintain accuracy of patient data
applying knowledge of the healthcare system, and practice policies and procedures to ensure accessibility of records.
Context of and specific resources for assessment
Assessment must ensure:
access to records system
documented procedures
access to an actual workplace or simulated environment
access to office equipment and resources.
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 new records created
analysis of responses to case studies and scenarios
demonstration of techniques
observation of presentations
oral or written questioning to assess knowledge of workplace emergencies, risks and hazards
observation of performance in role plays
assessment of archived patient files
assessment of recommendations made for improvements to the procedures and processes for maintaining patient records.
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 |
|---|---|---|---|
| C6998 | BSBMED303A | Maintain patient records | Unit of competency |
Replaced By
| State Code | National Code | Title | Type |
|---|---|---|---|
| AUI77 | BSBMED303 | Maintain patient records | Unit of competency |
| State Code | National Code | Title | Type |
|---|---|---|---|
| J064 | HLT32412 | Certificate III in Allied Health Assistance | Qualification |
| J343 | BSB31112 | Certificate III in Business Administration (Medical) | Qualification |
| D142 | BSB31107 | Certificate III in Business Administration (Medical) | Qualification |
| J069 | HLT32912 | Certificate III in Health Administration | Qualification |
| D076 | HLT43207 | Certificate IV in Health Administration | Qualification |
| J095 | HLT43312 | Certificate IV in Medical Practice Assisting | Qualification |