HLTCCD006 - Undertake basic clinical coding

Unit code: HLTCCD006 | Study level: TAFE
Nominal hours:
120
Location
Online
Prerequisites
HLTCCD005 - Abstract information for clinical coding
(Or equivalent to be determined by unit coordinator)
Overview
Enquire

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.

Students will also be expected to demonstrate the following knowledge:

  • definition of a clinical coder and clinical coding, and the purpose of coded clinical data
  • codes of practice and guidelines in relation to clinical coding, including professional ethics
  • Australian and State/Territory clinical coding standards and protocols
  • rules and conventions applied to clinical data and relevant to coding
  • sequencing protocols for clinical coding, including those for principal, additional diagnoses and interventions
  • timescales within which clinical coding must take place
  • key performance indicators (KPI’s) and quality indicators for coded clinical data
  • classifications and nomenclature relevant to clinical coding
  • coding classifications, standards and conventions for:
  • 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.

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.

Search for units, majors & minors