Unit Overview
Unit Title
BSBMED303 – Maintain Patient Records
Unit Purpose
This unit describes the skills and knowledge required to maintain patient record within an existing medical records management system, under the supervision of a senior receptionist or practice manager.
Prerequisites
There are no pre-requisites for this unit.
Content
Section 1: Introduction to Maintaining Patient Records
Section 2: Accessing Patient Records
Section 3: Maintaining Patient Records and Monitoring Own Role
Resources/Readings
Readings A – D are located in the associated Book of Readings.
Suggested Hours
Although everyone will work at their own pace, we suggest you allow approximately 60 hours to complete this unit competently, including seminars, tutorials, assignments and practical activities.
Timeframe
The recommended time frame for this unit is 4 weeks.
Assessment
This unit will be assessed by completing the BSBMED303 Assessment.
How to Use This Module
This module and associated BSBMED303 Readings contain all of the information that you need to complete the assessment tasks associated with this unit. You must read through all of the information provided (both the module and associated readings) before attempting the assessment tasks.
Throughout this module, there are a few coloured boxes used to help you. These include:
Tip
This is used to indicate the presence of tips or additional instructions that may assist you as you work through this module. They are designed to help you expand your knowledge and skills and deepen your understanding of how concepts and practices are applied in workplaces.
Read
You will find these throughout the module. They indicate that a particular Reading contains additional information on the topic that is being discussed at that point.
Reflect
This indicates a self-reflection question. You are not required to submit answers to these questions. They are designed to get you thinking more about the topic and to consider key points in order to aid your understanding.
Upon completion of this unit, you should be able to:
| Element | Performance Criteria |
|---|---|
| 1. Identify and clarify own role and procedures for patient recordkeeping | 1.1. Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual 1.2. Access documented procedures for patient recordkeeping 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 records according to organisational policy and procedures |
| 3. Help maintain records | 3.1. Make required checks of patient records 3.2. Carry out archiving of patient records as required 3.3. Transfer patient records 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 |
Knowledge Evidence
The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the work role. This includes knowledge of:
- Outline relevant legislation, standards and/or codes of practice that affect patient recordkeeping
- explain workplace policies and procedures related to patient recordkeeping, including privacy and confidentiality
- describe the process used to set up and maintain a patient record
- explain how coding systems help users to access and to maintain patient records.
Performance Evidence
The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:
- use a recordkeeping system to create, access, store and maintain accurate records, according to organisational and legislative requirements
- identify and recommend improvements to recordkeeping system or own work practices
- communicate with relevant people about patient records.
Introduction
This unit is designed to help you learn the skills and knowledge required to maintain patient record within an existing medical records management system, under the supervision of a senior receptionist or practice manager.
Overview of Sections
Section 1: Introduction to Maintaining Patient Records
This section of the Study Guide will provide you with an introduction to maintaining patient records, including the roles and responsibilities that you may hold. This section also introduces you to some privacy legislation related to patient recordkeeping, as well as how you could seek clarification regarding your role.
Section 2: Accessing Patient Records
In this section, you will learn more about the keys skills that you will need in order to access patient records. You will learn how to check patient information for accuracy and currency as well as how to create a new patient record. This section will also provide you information on how to store patient record such that it is in compliance with legislative requirements.
Section 3: Maintaining Patient Records and Monitoring Own Role
In this section of the Study Guide, you will learn how to maintain patient records, specifically how to archive and destroy patient records in a safe and secured manner. You will also learn about transferring patient records to other healthcare facilities under patient request. We will then look at how you could monitor and review your own role related to patient recordkeeping and how to make recommendations to improve the relevant procedures.
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