Part A: Course Overview

Program: C4428 Certificate IV in Allied Health Assistance

Course Title: Maintain Patient Records

Portfolio: Vocational Education

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.

Terms

Course Code	Campus	Career	School	Learning Mode	Teaching Period(s)
OFFC5362C	City Campus	TAFE	535T Social Care and Health	Face-to-Face or Internet	Term1 2025

Flexible Terms

Course Code	Campus	Career	School	Learning Mode	Teaching Period(s)
OFFC5370C	Bundoora Campus	TAFE	535T Social Care and Health	Face-to-Face or Internet	VE 2025 (BU25), VE 2025 (All)

Course Contact: Richa Verma

Course Contact Phone: +61 3 9925 4445

Course Contact Email: richa.verma@rmit.edu.au

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.

Pre-requisite Courses and Assumed Knowledge and Capabilities

Nil

National Competency Codes and Titles

National Element Code & Title:

BSBMED303 Maintain Patient Records

Elements:

1. Identify and clarify own role and procedures for patient recordkeeping 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 2. Access patient records 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 3. Help maintain records 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 4. Monitor and review own role 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

Overview of Assessment

Assessment methods may include any of the following:

• role plays
• case studies
• group work
• presentations
• practical assessments
• knowledge quizzes