HLTCCD002 - Interpret and navigate health care records

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Unit code: HLTCCD002 | Study level: TAFE
Credit points
N/A
Location
Online
Prerequisites
HLTCCD001 - Apply an understanding of the health care system to clinical coding practice
(Or equivalent to be determined by unit coordinator)
Overview
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Overview

This unit describes the performance outcomes, skills and knowledge required to accurately interpret information in health care records to support accurate clinical coding of an episode of care.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.

Assessment

For Melbourne campuses

Assessment tasks will be designed to reinforce & extend knowledge and skill competence within set & controlled parameters in accordance with each units learning outcomes & 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:

  • identify at least three different national or jurisdictional policies and how they impact on clinical coding work
  • identify at least three models of health care service funding including:
  • principles and purpose
  • effect on clinical coding procedures
  • for at least three different health care service providers identify:
  • structure and functions
  • the range of health professional roles and how they support patient outcomes
  • variations in patient management pathways
  • how the above factors impact on clinical coding work.

Students will also be expected to demonstrate the following knowledge:

  • national and jurisdictional legislation, agreements and policies relating to clinical coding
  • scope, structure and functions of public and private hospital and other health care service providers
  • roles of health care professionals:
  • types of roles
  • scope of practice of roles
  • responsibilities and reporting lines
  • clinical disciplines as listed on the Australian Health Practitioner Regulation Agency (AHPRA) website for registered practitioners
  • funding models for health care service providers:
  • source
  • purpose
  • structure
  • concept of clinical coding and Diagnosis Related Groups (DRG)
  • uses of coded data including health care services planning and monitoring, research, epidemiology, funding model development and quality * improvement activities
  • different pathways for management of patients:
  • non-admitted
  • emergency
  • admitted including same day admissions
  • sub-acute and non-acute
  • post discharge
  • impact of incorrect coding of clinical data
  • external factors influencing the health care system and their impact on clinical coding outcomes:
  • political
  • economic
  • social.

Required reading

The qualified trainer and assessor will provide teaching and learning materials as required in the form of workbooks produced by the VU Polytechnic and/or via the VU Polytechnic e-learning system.

As part of a course

This unit is studied as part of the following course(s):

Diploma of Clinical Coding
HLT50321 | Diploma | Duration:

Refer to the course page for information on how to apply for the course. VU takes care to ensure the accuracy of this unit information, but reserves the right to change or withdraw courses offered at any time. Please check that unit information is current with the Student Contact Centre.

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