Unit of competency Outline

Date retreived
22/07/2026 5:07 PM AWST

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Produce coded clinical data

Produce coded clinical data

Unit of competency
National Code
HLTADM005
State Code
AVB14
TGA Status
Replaced
DTWD Status
Transition (Replaced)
Current Release Number
1.00
Current Release Date
06/08/2015
View on TGA
State Implementation and Classification
Approved Date
22/01/2016
Field of Education
080905 - Practical Computing Skills
Original Release Date
22/01/2016
Nominal Hours
20
Description
This unit describes the skills and knowledge required to extract the correct clinical data from simple medical records. A simple medical record is defined as a medical record generated by an episode of care involving day stay, day surgery, planned surgery or simple medical problems with an average length of stay.This unit applies to clinical coders.The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.
Notes
Elements and Performance Criteria
1. Identify and evaluate clinical data from simple medical records
  • 1.1 Identify the principal diagnosis and principal procedure for an admission when coding from a simple medical record
  • 1.2 Identify additional diagnosis and procedures when coding from a simple medical record with specialties
  • 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 principal 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 International statistical classification of diseases and related health problems (ICD-10-AM), disease and procedures codesabstracted from simple medical records
  • 2.2 Apply Australian coding standards (ACS) where appropriate, to ensure the correct assignment of codes when coding simple medical records for specialities
  • 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 Enter the coded data accurately into the client system appropriate
  • 2.6 Complete the process of assigning the correct codes from clinical data within appropriate timeframes
  • 2.7 Maintain confidentiality of medical records and client information at all times
No information
No information
Replaces
State Code National Code Title Type
D5816 HLTCC301B Produce coded clinical data Unit of competency
Replaced By
State Code National Code Title Type
ODI91 HLTCCD006 Undertake basic clinical coding Unit of competency