This unit describes the skills and knowledge required to manage a patient recordkeeping system within a medical environment and to supervise others. It covers clarifying roles and responsibilities, managing the operation of a patient recordkeeping system, and reviewing and improving the system. The unit does not cover the design of a new system but does cover reviews and improvements to an existing system.

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: - manage a patient recordkeeping system and supervise its use; - document how records have been accessed and archived by staff or self in accordance with organisational and legislative requirements, and; - provide activities to others that support correct use of a patient record system. Note: if a specific volume or frequency is not stated, then evidence must be provided at least once.Students will also be expected to demonstrate the following knowledge: - outline relevant legislation, regulations, standards and codes of practice for maintaining records in a medical environment; - explain enterprise policies and procedures; - patient recordkeeping including archiving and records transfer; - privacy and confidentiality; - access to records; - describe filing systems and 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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