Unit of competency Outline

Date retreived
22/07/2026 5:43 AM AWST

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Abstract information for clinical coding

Abstract information for clinical coding

Unit of competency
National Code
HLTCCD005
State Code
ODI70
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
80
Description
This unit describes the performance outcomes, skills and knowledge required to identify and abstract clinical information from a patient health care record for clinical coding.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. Evaluate clinical information from health care records.
  • 1.1. Determine method of accessing patient information held in health care records and Patient Administration System (PAS).
  • 1.2. Interpret patient health care records completed by health care professionals.
  • 1.3. Establish validity of clinical information and patient demographic and administrative data sourced in relation to episode of care being coded.
  • 1.4. Confirm documentation supports coding criteria in detail required to meet coding requirements.
  • 1.5. Identify ambiguous, absent and incomplete documentation and data in health care records that could affect code assignment.
2. Abstract clinical data from health care records.
  • 2.1. Identify principal diagnosis according to current coding standards for an episode of care from information identified in patient health care record.
  • 2.2. Identify additional diagnoses from identified patient information according to current coding standards.
  • 2.3. Identify condition onset flags for diagnosis codes.
  • 2.4. Identify interventions from identified patient information according to current coding standards.
  • 2.5. Identify data required for coding and reporting.
  • 2.6. Use reference material to assist in clarifying information.
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State Code National Code Title Type
BGW4 HLT50321 Diploma of Clinical Coding Qualification
AWM6 HLT37315 Certificate III in Health Administration Qualification