Course Title: Manage patient record keeping system

Part A: Course Overview

Program: C4320 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)


City Campus


155T Vocational Health and Sciences

Face-to-Face or Workplace

Term2 2014,
Term1 2015,
Term1 2016

Course Contact: Suzanne Dellas Fatone

Course Contact Phone: +61 3 9341 1406

Course Contact Email:

Course Description

This unit describes the performance outcomes, skills and knowledge 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.

No licensing, legislative, regulatory or certification requirements apply to this unit at the time of endorsement.

This unit applies to individuals managing an existing record keeping system (and sub systems within the overall system) in a medical context. It may involve supervising the work of other personnel who implement the system and maintain patient records day to day. It also involves working with users of the system such as the health practitioners in the facility.

The unit does not cover the design of a new system but does cover reviews and improvements to an existing system. BSBMED303B Maintain patient records, covers the day to day implementation of the system.

Pre-requisite Courses and Assumed Knowledge and Capabilities

Not applicable

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. Access policies and procedures for patient records
1.2. Consult relevant personnel about how the system operates
1.3. Determine roles and responsibilities for the system operations
1.4. Communicate roles and responsibilities for system operations to relevant personnel

2.1. Supervise staff maintaining patient records
2.2. Provide staff maintaining patient records with training as required
2.3. Regularly consult staff using patient records about system efficacy
2.4. Maintain integrity of patient records
2.5. Maintain security of patient records
2.6. Stress importance of confidentiality of patient records to all staff, including self, who handle or have access to patient files
2.7. Provide authorisation of transfer of records from facility according to practice protocols
2.8. Archive records as appropriate

3.1. Monitor and review implementation of the system to identify improvements
3.2. Make recommendations to relevant personnel for system improvements
3.3. Implement approved recommendations
3.4. Supervise staff maintaining patient records to implement changes
3.5. Plan and deliver any required training for staff to implement changes made to the system

Overview of Assessment

Assessment will include demonstration of underpinning knowledge, and skills; assessment activities may include oral presentation, written work and third party report.