NZQA registered unit standard
18180 version 4
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Title
Produce text processed clinical documents
Level
4
Credits
10
Purpose
People credited with this unit standard are able to: produce
clinical documents from printed information, and produce a
range of clinical documents from recorded dictation sources
under normal operating conditions.
Classification
Business Administration > Business Information Processing
Available grade
Achieved
Entry information
Recommended skills
and knowledge
Unit 112, Produce business or organisational information using
word processing functions; and/or Unit 108, Apply text
processing skills to produce business documents.
Explanatory notes
1
All activities associated with this unit standard must comply with occupational health
and safety guidelines and recommendations in relation to working environment and
work practices. Reference for this unit standard includes How to use your visual
display unit safely. Worksafe New Zealand, available at
http://www.business.govt.nz/worksafe/information-guidance/all-guidanceitems/visual-display-unit-safely-how-to-use-your/howtousevdu.pdf.
2
The following legislation and subsequent amendments provide reference, where
needed, for this unit standard:
Health and Safety in Employment Act 1992.
3
Transcription is based on a 97% level of accuracy that allows three errors per 100
words dictated. Only one error is attributable to one word and five keystrokes represent
an average word. Keystrokes include punctuation and spacing. Dictionaries for English
language and specialist terms, meeting procedure references, and trade and business
resources may be used during transcription.
4
Definitions
Normal operating conditions refer to conditions that reflect a realistic work
environment in terms of background noise and interruptions. This results in recorded
dictation of variable quality requiring some editing and amendments.
Clinical documents refer to documents in all branches of the health service sector.
NZQA National Qualifications Services
SSB Code 130301
 New Zealand Qualifications Authority 2016
NZQA registered unit standard
5
18180 version 4
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Reference sources for this unit standard include:
any medical dictionary based on English rather than American spelling conventions;
The Merck Manual of Diagnosis and Therapy, 19th edition, available at
http://www.merck.com/mmpe/index.html.
Outcomes and evidence requirements
Outcome 1
Produce clinical documents from printed information.
Range
evidence of five documents is required.
Evidence requirements
1.1
Spelling, grammar, and vocabulary are consistent with the nature and purpose
of the output required.
Range
vocabulary includes – medical terminology.
1.2
Medical terminology sources are used and referenced in accordance with
information provided and output required.
1.3
Information is interpreted and clinical documents are produced in accordance
with the information provided and output required.
Range
information may include but is not limited to – hand-written,
printed, amended notes.
Outcome 2
Produce a range of clinical documents from recorded dictation sources under normal
operating conditions.
Range
may include but is not limited to – referral letter, clinic letter, clinical report,
operation note, discharge letter;
evidence of 15 documents in total.
Evidence requirements
2.1
Documents produced are consistent with the dictated instructions, information
provided, and output required.
2.2
Display principles and editing techniques are applied to enhance document
appearance and are consistent with the output required.
Range
principles and techniques may include but are not limited to –
page layout, font selection and size, text formatting, use of lines,
boxes, borders, autotext, templates, custom dictionary;
evidence of five is required, but not necessarily all in each
document.
NZQA National Qualifications Services
SSB Code 130301
 New Zealand Qualifications Authority 2016
NZQA registered unit standard
2.3
18180 version 4
Page 3 of 3
Editing, formatting and layout of information conform to organisational
requirements and are consistent with the nature and purpose of the output
required.
Planned review date
31 December 2019
Status information and last date for assessment for superseded versions
Process
Version Date
Last Date for Assessment
Registration
1
22 March 2001
31 December 2011
Review
2
26 September 2005
31 December 2012
Review
3
17 December 2010
31 December 2017
Rollover and
Revision
4
16 April 2015
N/A
Consent and Moderation Requirements (CMR) reference
0113
This CMR can be accessed at http://www.nzqa.govt.nz/framework/search/index.do.
Please note
Providers must be granted consent to assess against standards (accredited) by NZQA,
before they can report credits from assessment against unit standards or deliver courses
of study leading to that assessment.
Industry Training Organisations must be granted consent to assess against standards by
NZQA before they can register credits from assessment against unit standards.
Providers and Industry Training Organisations, which have been granted consent and
which are assessing against unit standards must engage with the moderation system that
applies to those standards.
Requirements for consent to assess and an outline of the moderation system that applies
to this standard are outlined in the Consent and Moderation Requirements (CMR). The
CMR also includes useful information about special requirements for organisations wishing
to develop education and training programmes, such as minimum qualifications for tutors
and assessors, and special resource requirements.
Comments on this unit standard
Please contact NZQA National Qualifications Services nqs@nzqa.govt.nz if you wish to
suggest changes to the content of this unit standard.
NZQA National Qualifications Services
SSB Code 130301
 New Zealand Qualifications Authority 2016