This unit describes the skills and knowledge to assign clinical classification codes to an admitted episode of care using patient and clinical data from medical records of moderately complex episodes of care.  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: - digital technology skills to access and use relevant computer programs; - digital literacy skills to navigate computer based programs to enable information to be entered accurately; - numeracy skills to apply and assess requirements for speed and accuracy; - self management skills to: access and organise references; maintain and update own knowledge and skills to ensure that amendments are addressed as required; make amendments to clinical coding activities according to organisational requirements, and; - analytical skills to determine appropriate codes relevant to the episode of care.Students will also be expected to demonstrate the following knowledge: - organisational procedures and protocols for: accessing medical records and maintaining the security of patient data; identifying timeframes and accuracy rates for coding admitted episodes; - relevant classification standards and conventions to enable accurate codes to be assigned, and; - guidelines in current condition onset flags and jurisdictional additions to enable the correct assignment of condition onset flags to codes.

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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