HLTCCD002 - Interpret and navigate health care records

Unit code:HLTCCD002Study level:TAFE

Nominal hours

Location

Footscray Nicholson
Industry
Online
Sunshine

Prerequisites

HLTCCD001 - Apply an understanding of the health care system to clinical coding practice
(Or equivalent to be determined by unit coordinator)
Co-requisites
(Corequisite units must be studied concurrently with this unit)

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 Victoria University and/or via the Victoria University e-Learning system.