Course Title: Manage patient record keeping system

Part A: Course Overview

Program: C4209 Certificate IV in Dental Assisting

Course Title: Manage patient record keeping system

Portfolio: SEH Portfolio Office

Nominal Hours: 50

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.

Course Code




Learning Mode

Teaching Period(s)

Course Contact: Ms. Eleanor Schroeder

Course Contact Phone: +61 3 931 1406

Course Contact Email:

Course Description

This unit specifies the outcomes required to manage a patient record system within a medical environment, and to supervise others. It covers clarifying roles and responsibilities, managing the operation of a patient records system, and reviewing and improving the system.

Pre-requisite Courses and Assumed Knowledge and Capabilities

No pre-requisites and Co-requisites required.

National Competency Codes and Titles

National Element Code & Title:

BSBMED401B Manage patient record keeping system


1. Clarify how patient records system operates
2. Manage operation of patient records system
3. Review and improve patient records system

Learning Outcomes

1.1 Policies and procedures for patient records are accessed
1.2 Relevant personnel are consulted about how the system operates
1.3 Roles and responsibilities for the system operations are determined
1.4 Roles and responsibilities for system operations are communicated to relevant personnel

2.1 Supervision of staff maintaining patient records is provided
2.2 Staff maintaining patient records are provided with training as required
2.3 Staff using patient records are regularly consulted about system efficacy
2.4 Integrity of patient records is maintained
2.5 Security of patient records is maintained
2.6 Importance of confidentiality of patient records is stressed to all staff, including self, who handle or have access to patient files
2.7 Authorisation of transfer of records from facility is provided
2.8 Records are archived as appropriate

3.1 Implementation of the system is monitored and reviewed to identify improvements
3.2 Recommendations are made to relevant personnel for system improvements
3.3 Approved recommendations are implemented
3.4 Staff maintaining patient records are supervised to implement changes
3.5 Any required training for staff to implement changes made to system is planned and delivered in a timely manner

Overview of Assessment

The assessment comprises of  a written assessment, oral presentation and thrid party evidence (Workplace Training Record Book).