MAINTAIN PATIENT RECORDS
Formative assessments
What resources are available to help medical administrative staff determine their own roles and responsibilities within patient recordkeeping system? (60−70 words)
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Why are patient records necessary? (150 words)
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List 10 types of information that might be included in patient medical records.
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What is the intent of privacy legislation and how does it impact on patient recordkeeping procedures in a medical practice? (50 words)
From where could medical practice administrative staff access documented procedures for patient recordkeeping? (80−100 words)
Why is it necessary to seek clarification of unclear or ambiguous procedures with relevant personnel? (50−60 words)
With whom can medical practice staff clarify unclear or ambiguous procedures? (40−50 words)
How might medical practice administrative staff check the currency and accuracy of patient demographic and personal details? (100−120 words)
Why is it necessary for patient records to be complete, accurate and current? (50−60 words)
List 10 pieces of personal information that might be required to create a new patient record according to enterprise protocol.
Medical administrative staff checks records following patient visits, for practitioners’ instructions related to follow-up actions. List three typical follow-up actions the staff might be required to complete in this scenario.
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What procedure might medical administrative staff follow to make appointments for a patient with a specialist? (60−80 words)
How does health and safety legislation impact on storing patient records? (150 words)
What are the advantages of a colour coded filing system? (40 words)
Patient records must be stored in areas that are regularly maintained and monitored to facilitate their security. Why is this important? (30 words)
Why should patient records be checked regularly? (30−40 words)
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When might the information in patient records be checked? (30−40 words)
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What information in patient records should be checked? (40−50 words)
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How can paper-based patient records be tracked if they are removed from their normal storage location for checking and why is this necessary? (40−50 words)
List two formats in which archiving of patient records can be carried out?
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How might administrative staff in a medical practice familiarise themselves with procedures of archiving patient records? (50−60 words)
What is a retention period? In general, what is the retention period for medical patient files? (70−80 words)
Provide four examples of circumstances where it might be necessary to transfer patient records to another health facility upon appropriate request for patient information.
Why is it necessary to gain authorisation from the patient to transfer information from their medical records to another health facility? (50−60 words)
In what circumstances, can medical practices transfer patient information to an organisation outside of Australia? (50−60 words)
Explain how monitoring and reviewing own role and responsibilities in maintaining patient records help identify opportunities for improvements to system and own work practices? (150−170 words)
What is continuous improvement and how does it relate to maintaining patient records? (100−120 words)
If medical practice administrative staff identify areas in need of improvement or opportunities that could make a beneficial difference to work practice, what should they do? What skills and personal qualities are required to identify improvement opportunities and communicate them to relevant personnel? (150−170 words)
In this practical you will need to show you can apply a broad range of competencies in various medical administration contexts. Remember you are a skilled operator who is expected to exercise discretion and judgement in accessing and maintaining patient records while fully respecting patient privacy and the confidentiality of your details.
Complete the following practical checklist which identifies tasks and activities. Submit / upload the completed checklist to your Assessor.
Tasks will include:
Complete this checklist (MyECampus practical) noting tasks to be completed including what might be involved in each of these responsibilities and the resources available to assist administrative staff to meet their responsibilities.