HLTCCD005 - Abstract information for clinical coding

Unit code: HLTCCD005 | Study level: TAFE
Nominal hours:
90
Location
Online
Prerequisites
HLTCCD002 - Interpret and navigate health care records; and
HLTCCD003 - Use medical terminology in health care; and
HLTCCD004 - Interpret clinical documentation using knowledge of anatomy and physiology
(Or equivalent to be determined by unit coordinator)
Overview
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Overview

This unit describes the performance outcomes, skills and knowledge required to identify and abstract clinical information from a patient health care record for clinical coding.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:

  • access and interpret clinical information from patient health care records for at least five episodes of care for each of the following:
  • infectious and parasitic diseases
  • neoplasms
  • diseases of the blood and blood-forming organs and common 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.

Students will also be expected to demonstrate the following knowledge:

  • types of clinical information:
  • correspondence
  • clinical notes
  • orders and prescriptions
  • operation, treatment and procedure reports
  • pathology investigation results
  • diagnostic imaging results
  • discharge summaries
  • abstracting and clinical coding methods to identify:
  • principal diagnoses, additional diagnoses and interventions
  • sequencing of diagnoses and interventions
  • ambiguous, absent and incomplete documentation and data
  • issues requiring clarification
  • organisational policies and procedures:
  • health care records storage and access
  • hard copy
  • electronic copy
  • coding clarification:
  • oral communication
  • written communication
  • selection of communication method
  • referral of unresolved issues:
  • oral communication
  • written communication
  • selection of communication method
  • protocols for referrals.

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.

As part of a course

This unit is studied as part of the following course(s):

Diploma of Clinical Coding
HLT50321 | Diploma | Duration:

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.

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