This unit describes the skills and knowledge to abstract clinical information from medical records to identify and extract clinical data required for clinical coding.This unit applies to those with responsibility for the coding of health service clinical data. 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: - establish that the clinical information sourced relates to the correct episode of care being assessed; - identify ambiguous, absent or incomplete documentation and/or data; - identify principal diagnosis, additional diagnoses and interventions; - identify sequencing of diagnoses and interventions; - identify and interpret information presented in a range of formats in clinical documentation; - navigate and identify accurate information from additional resources such as medical dictionary and Monthly Index of Medical Specialties (MIMS); - writing skills to compose clear and concise paper based and/or electronic communications to clinical health professionals or other coding staff to clarify coding issues; - oral communication skills to make and respond to verbal inquiries and negotiate conversations with peers and clinical health professionals; - self management skills to access and organise relevant references, and; - digital technology skills to store and retrieve information in digital format.Students will also be expected to demonstrate the following knowledge: - enable appropriate written and oral communications with clinical health professionals to clarify coding queries; - refer unresolved issues; - correct interpretation of clinical documentation; - clear and accurate communication with clinical health professionals to clarify coding queries, including the meaning of Latin roots, suffixes and prefixes; - structure of normal functioning body systems to enable accurate interpretation of clinical information for coding; - concepts underpinning human anatomy and physiology to enable accurate interpretation of clinical information for coding; - levels of structural organisation of body systems; - human life processes, and; - homeostasis and the relationship between homeostatic imbalance and disease.

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.

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.