HLTCCD006 - Undertake basic clinical coding
Overview
This unit describes the performance outcomes, skills and knowledge required to assign clinical classification codes to an admitted episode of care using patient and clinical data from basic patient health care records.This unit applies to clinical coders who are responsible for understanding and extracting patient clinical information for the purposes of clinical coding.
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:
- use current coding manuals and standards to produce coded clinical data from basic patient health care records for at least ten episodes of care for each of the following:
- infectious and parasitic diseases
- neoplasms
- diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
- endocrine, nutritional and metabolic diseases
- mental and behavioural disorders
- diseases of the nervous system
- diseases of the eye and adnexa
- diseases of the ear and mastoid process
- diseases of the circulatory system
- diseases of the respiratory system
- diseases of the digestive system
- diseases of the skin and subcutaneous tissue
- diseases of the musculoskeletal system and connective tissue
- diseases of the genitourinary system
- pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities
- symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified
- injury, poisoning and causes of morbidity and mortality
- for each of the above, use reference materials to inform code assignment for unfamiliar clinical concepts
- for the above, episodes of care should collectively include the following:
- same-day episodes of care cases
- minor injuries
- basic surgeries
- overnight episodes of care
- both acute and chronic forms of a disease or condition.
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):