This unit describes the skills and knowledge to correctly interpret information in clinical documentation to support accurate clinical coding.  This unit applies to those with responsibility for interpreting and extracting patient clinical information for the purposes of clinical coding. Work may be performed as an individual or as part of team under limited supervision.

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: - analytical skills to determine the relationship between clinical documentation and the accurate coding of medical information, and; - literacy skills to read and synthesise information from clinical documentation to identify the interrelationships that impact on accurate clinical coding.Students will also be expected to demonstrate the following knowledge: - organisational protocols for: the storage, access and use of medical records and patient data; clarifying issues affecting clarity and accuracy of clinical documentation; - structure of normal functioning body systems to enable accurate identification of clinical information for coding; - concepts underpinning human anatomy and physiology to enable accurate identification of clinical information for coding; - common and medical anatomical terminology to enable interpretation of clinical documentation and clear communication with clinical health professionals, and; - methods of referencing information in current medical dictionary used for clinical coding.

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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