Unit of competency Outline
Date retreived
23/07/2026 4:53 AM AWST
23/07/2026 4:53 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.
Undertake complex clinical coding
Undertake complex clinical coding
Unit of competency
National Code
HLTCC401B
HLTCC401B
State Code
D5817
D5817
TGA Status
Replaced
Replaced
DTWD Status
Replaced
Replaced
State Implementation and Classification
Approved Date
02/08/2011
Field of Education
010103 - Statistics
Original Release Date
02/08/2011
Nominal Hours
20
Description
DescriptorThis unit of competency describes the skills and knowledge required to undertake coding of moderately complex discharge summaries, medical reports and medical records, including the selection of the primary diagnosis and sequencing of other diagnoses for coding
Notes
Elements and Performance Criteria
1. Abstract clinical data from moderately complex medical records
- 1.1 Interpret and apply the Australian National Coding Standards to identify clinical data from moderately complex discharge summaries, medical reports and medical records
- 1.2 Select appropriate conditions/diseases and procedures for coding from moderately complex medical records
- 1.3 Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records
- 1.4 Identify additional diagnoses and procedures
- 1.5 Establish the correct sequencing of diagnoses and procedures
2. Assign codes relating to moderately complex medical records
- 2.1 Apply Australian National Coding Standards where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties
- 2.2 Assign complete and accurate ICD-10-AM disease and ACHI procedure codes
- 2.3 Utilise resources where appropriate to assist in making coding decisions
- 2.4 Recognise problems relating to privacy and confidentiality of client information
- 2.5 Maintain confidentiality of medical records and client information at all times
- 2.6 Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes
- 2.7 Meet occupational health and safety duty of care requirements
3. Maintain clinical coding records
- 3.1 Record, enter, edit and maintain a client information system of coded data (disease index)
- 3.2 Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation
- 3.3 Make amendments to data collection and coding activities in line with organisation requirements
- 3.4 Maintain and update own knowledge and skills to ensure that amendments are addressed as required
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.
Moderately complex medical records refer to:
Medical records resulting from an episode of care generally seen in health care facilities ranging from large to small size hospitals (AIHW National Hospital Peer Group Classifications A1-D1)
Medical information may be obtained from:
discharge summaries
medical reports
medical records
Resources may include:
MIMS
Medical abbreviations dictionary
Disease and procedure codes may include:
Coding for:
endocrine and musculoskeletal diseases
genitourinary, pregnancy, childbirth, the puerperium, the perinatal period and congenital conditions
infectious and blood diseases
injuries and poisonings
mental health
neoplasms, digestive and skin diseases
nervous system, eye, ear, nose and mouth diseases
respiratory and circulatory diseases
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.
Moderately complex medical records refer to:
Medical records resulting from an episode of care generally seen in health care facilities ranging from large to small size hospitals (AIHW National Hospital Peer Group Classifications A1-D1)
Medical information may be obtained from:
discharge summaries
medical reports
medical records
Resources may include:
MIMS
Medical abbreviations dictionary
Disease and procedure codes may include:
Coding for:
endocrine and musculoskeletal diseases
genitourinary, pregnancy, childbirth, the puerperium, the perinatal period and congenital conditions
infectious and blood diseases
injuries and poisonings
mental health
neoplasms, digestive and skin diseases
nervous system, eye, ear, nose and mouth diseases
respiratory and circulatory diseases
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:
Assessment must be completed in the workplace
Relevant guidelines, standards and procedures
Resources essential for assessment include:
ICD-10-AM, ACHI and ACS and relevant local coding requirements
a range of complex medical records
resources material
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:
Assessment must be completed in the workplace
Relevant guidelines, standards and procedures
Resources essential for assessment include:
ICD-10-AM, ACHI and ACS and relevant local coding requirements
a range of complex medical records
resources material
Replaces
| State Code | National Code | Title | Type |
|---|---|---|---|
| C9125 | HLTCC401A | Undertake complex clinical coding | Unit of competency |
Replaced By
| State Code | National Code | Title | Type |
|---|---|---|---|
| AVB13 | HLTADM006 | Undertake complex clinical coding | Unit of competency |
| State Code | National Code | Title | Type |
|---|---|---|---|
| J094 | HLT43212 | Certificate IV in Health Administration | Qualification |