This unit describes the skills and knowledge required to maintain patient records within an existing medical records management system, under the supervision of a senior receptionist or practice manager. It applies to individuals who apply a broad range of competencies in various medical administration contexts. They are skilled operators who are expected to exercise discretion and judgement in accessing and maintaining patient records while fully respecting patient privacy and the confidentiality of their details.

Unit details

Study level:
Vocational and further education (TAFE)
Unit code:


Assessment tasks will be designed to reinforce and extend knowledge and skill competence within set and controlled parameters in accordance with each unit's learning outcomes and performance criteria requirements, including the setting of work based practical application tasks designed to provide evidence of competence outcomes, within periodic and scheduled timelines. Students will be expected to demonstrate the following required skills: - use record and file management systems to create, access, store and maintain accurate records, according to organisational requirements; - identify and recommend improvements to record keeping system or own work practices, and; - communicate with relevant people about patient data.Students will also be expected to demonstrate the following knowledge: - outline relevant legislation, regulations, standards and codes of practice that affect patient recordkeeping; - explain workplace policies and procedures related to patient recordkeeping, including privacy and confidentiality; - describe filing record management processes, and; - explain how medical coding is used to help access and maintain patient records.

Where to next?

As part of a course

This unit is studied as part of the following courses. Refer to the course page for information on how to apply for the course.

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