Course Title: Maintain Patient Records
Part B: Course Detail
Teaching Period: Term1 2024
Course Code: OFFC5362C
Course Title: Maintain Patient Records
School: 535T Social Care and Health
Campus: City Campus
Program: C4428 - Certificate IV in Allied Health Assistance
Course Contact: Tino D'Angelo
Course Contact Phone: +61 3 9925 4380
Course Contact Email: tino.dangelo@rmit.edu.au
Name and Contact Details of All Other Relevant Staff
Nominal Hours: 20
Regardless of the mode of delivery, represent a guide to the relative teaching time and student effort required to successfully achieve a particular competency/module. This may include not only scheduled classes or workplace visits but also the amount of effort required to undertake, evaluate and complete all assessment requirements, including any non-classroom activities.
Pre-requisites and Co-requisites
Nil
Course Description
This unit describes the skills and knowledge required to maintain patient records within an existing medical records management system, under the supervision of a senior receptionist or practice manager.
It applies to individuals who apply a broad range of competencies in various medical administration contexts. They are skilled operators who are expected to exercise discretion and judgement in accessing and maintaining patient records while fully respecting patient privacy and the confidentiality of their details.
National Codes, Titles, Elements and Performance Criteria
National Element Code & Title: |
BSBMED303 Maintain Patient Records |
Element: |
1. Identify and clarify own role and procedures for patient recordkeeping |
Performance Criteria: |
1.1 Determine own role and responsibilities within patient recordkeeping system through consultation with relevant personnel or via organisational policy and procedures manual 1.2 Access documented procedures for patient recordkeeping system and read for understanding 1.3 Seek clarification with relevant personnel of unclear or ambiguous procedures |
Element: |
2. Access patient records |
Performance Criteria: |
2.1 Gain access to patient records to facilitate patient visit 2.2 Check currency and accuracy of patient demographic and personal details 2.3 Create new records according to enterprise protocols 2.4 Check records following patient visits, for practitioners' instructions related to follow-up action 2.5 Store patient records according to organisational policy and procedures |
Element: |
3. Help maintain records |
Performance Criteria: |
3.1 Make required checks of patient records 3.2 Carry out archiving of patient records as required 3.3 Transfer patient records to another health facility upon appropriate request for patient information |
Element: |
4. Monitor and review own role |
Performance Criteria: |
4.1 Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices 4.2 Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records |
Learning Outcomes
Details of Learning Activities
This course will be delivered as a face to face learning course.
A combination of activities will support students learning in this course, such as:
- Face to face and online lectures to cover theoretical and practical concepts for each topic in the course. The students will be provided with self-study materials as well.
- Self paced learning.
- Tutorial activities (individually and in teams) to discuss, debate, critique and consolidate your ideas and extend your understanding around key concepts within specific topics
- Online and face to face discussion and activities to support you to collaborate with other students in your course and debate and debate and discuss ideas (optional activities only)
- Self-directed study time to enhance and strengthen your knowledge and understanding of theoretical concepts
- To further facilitate learning, students are strongly encouraged to use a range of communication tools between themselves and their course instructor as well as between themselves and fellow students by using the online learning platform
Teaching Schedule
Week 1 |
Topic |
Task |
Mode of Delivery |
Week 1 |
Introduction to unit, requirements of the unit, and Assessment related to unit discussed Identify your role, and procedures for patient record keeping Relevant Legislation standards and/or codes of practice that affect patient recordkeeping Workplace policies and procedures related to patient recordkeeping, including privacy and confidentiality |
|
Face to Face |
Week 2 |
Accessing patient records Types of record systems Explain how coding systems help users to access and to maintain patient records |
Face to Face |
|
Week 3 |
Describe the process used to set up and maintain a patient record Revision and Assessment discussion Knowledge Assessment |
AT1 Knowledge Assessment |
Face to Face |
Week 4 |
Final Practical
|
AT2 Observation Assessment |
Face to Face |
Learning Resources
Prescribed Texts
References
Other Resources
RMIT Library
http://www1.rmit.edu.au/library
The University Library has extensive resources and provides subject specialist expertise, research advice, help with referencing and support through:
The Learning Lab
https://www.rmit.edu.au/students/study-support/learning-lab
The Study Support Hub
https://www.rmit.edu.au/students/study-support/study-support-hub
English for uni workshops
https://www.rmit.edu.au/students/study-support/workshops/english-uni-workshops
Overview of Assessment
Assessment methods may include any of the following:
- role plays
- case studies
- group work
- presentations
- practical assessments
- knowledge quizzes
Assessment Tasks
Students must successfully complete two (2) assessment tasks to be deemed competent in this course:
- Assessment Task 1 - Knowledge Test
- Assessment Task 2 - Product/Practical Task
Assessment Task 1
This is an individual assessment task.
This is an 'open book’ assessment. Students are allowed to revisit the online modules for this course and access websites to help formulate your correct answers.
This task allows you to demonstrate the knowledge required to maintain patient records within an existing medical records management system, under the supervision of a senior receptionist or practice manager and Allied Health Professional.
The task will be made available for students in week 3. Students will have access for 2 weeks, and it is due in week 5.
Assessment Task 2
In this assessment students are required to follow workplace processes to create, store, access and maintain records using a simulated scenario.
Students are required to:
- Access the SharePoint record keeping system and confirm any details with Clinic Manager that you are unsure of
- Create new client records – use Patient Record template (Appendix 1)
- Maintaining records – update Patient Record template
- Archive a record - update Patient Record template
- Transfer a record- update Patient Record template and Consent form
- Discuss in your group and then answer self-evaluation questions:
- How can you help identify opportunities for improvement?
- Who would you consult?
This assessment will be conducted during class time in week 4.
Grades
The students will receive satisfactory/ not yet satisfactory result for each assessment task. The students can receive Competency achieved/ Not yet competent result for this competency.
The details about the assessments will be posted on canvas.
The students are required to receive satisfactory result in each task to receive a competency achieved result for this unit.
Students enrolled in Vocational Education and Training qualifications are assessed for Competency. To be assessed as Competent means you have consistently demonstrated the required knowledge and skills at a standard expected in the workplace.
To be assessed as Competent in this course, you will need to complete each assessment task to a satisfactory standard. You will receive feedback from the teacher at the conclusion of each assessment task.
USE OF AI TOOLS IN THE ASSESSMENTS:
AI tools cannot be used in the completion of any of the above assessment tasks.
In these assessment tasks, you must not use any AI tools (excluding text editing software e.g., Grammarly) to generate any materials, content or ideas related to the task.
Results that apply to courses that are delivered and assessed in accordance with competency-based assessment are:
CA: Competency Achieved
NYC: Not Yet Competent
DNS: Did not Submit for Assessment
Assessment Matrix
The assessment matrix demonstrates alignment of assessment tasks with the relevant unit of competency. These mapping documents are available through Program Administration if required.
Other Information
Attendance:
This course is delivered via face to face sessions.
It is strongly advised that you attend all sessions. This will allow you to engage in the required learning activities, ensuring you the maximum opportunity to complete this course successfully and ask for any required information that you will need any assistance.
Information about your studies:
You can access My Studies through the RMIT website for information about timetables, important dates, assessment dates, results and progress, Canvas etc.
https://www.rmit.edu.au/students
Extensions of time for submission of assessable work:
If you are prevented from submitting an assessment on time by circumstances outside your control you may apply for an extension of up to seven (7) calendar days by applying through CANVAS - Assessment Extension tab. Eligibility criteria for application and the form is available from the link: https://www.rmit.edu.au/students/student-essentials/assessment-and-exams/assessment/extensions-of-time-for-submission-of-assessable-work
Where an extension of greater than seven days is needed, you must apply for special consideration.
Special consideration:
If due to illness or other unforeseen circumstance, you are unable to attend on the due date of an assessment (e.g. test, examination, oral, etc.), you may submit an application for special consideration within 5 working days of the due date. If special consideration is granted, you will be given the opportunity to complete/repeat the assessment task at a later date. For advice on this application please visit www.rmit.edu.au/students/specialconsideration or speak to your Program Coordinator.
Academic Integrity and Plagiarism:
RMIT University has a strict policy on plagiarism and academic integrity. Please refer to the website for more information on this policy.
https://www.rmit.edu.au/students/student-essentials/assessment-and-exams/academic-integrity
Credit Transfer and Recognition of Prior Learning:
Credit transfer is the recognition of previously completed formal learning (an officially accredited qualification).
Recognition of Prior Learning (RPL) is an assessment process that allows you to demonstrate competence using the skills you have gained through experience in the workplace, voluntary work, informal or formal training or other life experiences.
Please speak to your teacher if you wish to discuss applying for Credit Transfer or RPL for the unit(s) of competency addressed in this course.
https://www.rmit.edu.au/students/student-essentials/enrolment/apply-for-credit
Course Overview: Access Course Overview