Advanced Search

Real Decree 543/1995, Of 7 April, Which Establishes The Title Of Technician In Health Documentation And The Corresponding Minimum Teachings.

Original Language Title: Real Decreto 543/1995, de 7 de abril, por el que se establece el título de Técnico superior en Documentación Sanitaria y las correspondientes enseñanzas mínimas.

Subscribe to a Global-Regulation Premium Membership Today!

Key Benefits:

Subscribe Now for only USD$40 per month.

TEXT

Article 35 of the Organic Law 1/1990 of 3 October, for the General Management of the Educational System, provides that the Government, after consulting the Autonomous Communities, will establish the titles corresponding to the vocational training, as well as the minimum teaching of each of them.

Once, by Royal Decree 676/1993 of 7 May, the general guidelines for the establishment of vocational training qualifications and their corresponding minimum teachings have been laid down, the Government should also After consulting the Autonomous Communities, as provided for in the abovementioned rules, establish each professional training title, set out their respective minimum teachings and determine the various aspects of the relevant academic organisation. to professional lessons which, without prejudice to the powers conferred on them Educational administrations responsible for the establishment of the curriculum of these teachings, guarantee a basic training common to all students.

For these purposes, the duration and level of the corresponding training cycle will be determined in each case; the convalidations of these teachings; the access to other studies and the minimum requirements of the institutions (i)

The teachers ' specialties to be taught must also be determined and, in accordance with the Autonomous Communities, the equivalence of qualifications for the purposes of teaching as provided for in the Additional provision of the Organic Law of 3 October 1990 on the General Management of the Educational System. Subsequent rules must, if necessary, complete the teaching of the teachers ' specialties defined in this Royal Decree with the professional modules that come from other formative cycles.

On the other hand, and in compliance with article 7 of the aforementioned Royal Decree 676/1993, of 7 May, it is included in this Royal Decree, in terms of professional profile, the expression of the professional competence characteristic of the title.

This Royal Decree establishes and regulates in the basic aspects and elements above the degree of professional training of the Technical Superior in Sanitary Documentation.

In its virtue, on the proposal of the Minister of Education and Science, consulted by the Autonomous Communities and, where appropriate, in agreement with them, with the reports of the General Council of Vocational Training and the School Council of the State, and after deliberation by the Council of Ministers at its meeting on 7 April 1995,

DISPONGO:

Article 1.

The degree of professional training of a higher technician is established in Sanitary Documentation, which will be of official character and validity throughout the national territory, and the corresponding minimum teachings are approved. they contain in the Annex to this Royal Decree.

Article 2.

1. The duration and level of the training cycle are as laid down in paragraph 1 of the Annex.

2. In order to access the professional studies regulated in this Royal Decree, the students will have to study the subjects of the baccalaureate as indicated in section 3.6.1 of the annex.

In order to take advantage of the learning cycle lessons, the students will have to take up the basic training content set out in section 3.6.2 of the annex. The competent educational authorities may include these contents in the subject matter or materials they deem appropriate and organise them in the sequence of impartition which they consider to be more appropriate in order to achieve the teaching of the training cycle.

3. The specialities required of the teaching staff providing teaching in the modules which make up this title, as well as the minimum requirements to be met by the educational establishments, are those expressed in paragraphs 4.1 and 5 of the Annex.

4. The subjects of the baccalaureate, which may be taught by the teachers of the specialties defined in this Royal Decree, are set out in paragraph 4.2 of the Annex.

5. In relation to the provisions of the 11th additional provision of the Organic Law 1/1990 of 3 October, the qualifications referred to in paragraph 4.3 of the Annex are declared equivalent for the purposes of teaching.

6. The modules which may be validated by occupational training or correspondence with the work practice are those specified in paragraphs 6.1 and 6.2 respectively of the Annex.

The modules that, in compliance with the conditions that are established, will be determined by agreement between the Ministry of Education and Science and the Ministry of Labor and Social Security.

7. The university studies to which this title gives access are those referred to in paragraph 6.3. of the Annex.

Single additional disposition.

In accordance with the provisions of Royal Decree 676/1993 of 7 May 1993 laying down general guidelines on diplomas and the corresponding minimum training courses for vocational training, the elements which are enuncian under the heading "Reference of the production system" in the number 2 of the Annex to this Royal Decree do not constitute a regulation of the exercise of profession entitled some and, in any case, will be understood in the context of the present Royal I decree with respect to the scope of the professional exercise linked by the legislation in force to the Professions entitled.

Final disposition first.

This Royal Decree, which is of a basic nature, is dictated by the powers conferred on the State in Article 149.1.30. of the Constitution, as well as in the first paragraph 2 of the Organic Law. The Law of 3 July 1985 on the Right to Education, and by virtue of the empowerment conferred on the Government by Article 4.2 of the Organic Law 1/1990 of 3 October of General Ordination of the Educational System.

Final disposition second.

It is up to the competent educational authorities to dictate how many provisions are precise, in the field of their competences, for the execution and development of the provisions of this Royal Decree.

Final disposition third.

This Royal Decree shall enter into force on the day following that of its publication in the "Official Gazette of the State".

Given in Madrid on April 7, 1995.

JOHN CARLOS R.

The Minister of Education and Science,

GUSTAVO SUAREZ PERTIERRA

ANNEX

INDEX

1. Title identification:

1.1 Naming.

1.2 Level.

1.3 Duration of the formative cycle.

2. Production system reference:

2.1 Professional profile:

2.1.1 General Competition.

2.1.2 Professional skills.

2.1.3 Competition Units.

2.1.4 Professional Realizations and Domains.

2.2 Evolution of professional competence:

2.2.1 Changes in technological, organizational and economic factors.

2.2.2 Changes in professional activities.

2.2.3 Changes in training.

2.3 Position in the production process:

2.3.1 Professional and work environment.

2.3.2 Functional and technological environment.

3. Minimum teachings:

3.1 General objectives of the training cycle.

3.2 Professional modules associated with a competency unit:

Organization of clinical files.

Definition and treatment of clinical documentation.

Coding of clinical and non-clinical data.

Validation and exploitation of healthcare databases.

3.3 Cross-sectional professionals:

General computer applications.

Relationships in the workbench.

3.4 Vocational training module in the workplace.

3.5 Professional training and guidance module.

3.6 Baccalaureate materials and other content of basic vocational training.

4. Teachers.

4.1 Teachers ' specialisms with teacher attribution in the modules of the training cycle.

4.2 Baccalaureate materials that can be taught by the teachers of the specialties defined in this Royal Decree.

4.3 Qualifications of qualifications for teaching purposes.

5. Minimum requirements for spaces and facilities to impart these teachings.

6. Convalidations, correspondences and access to university studies:

6.1 Professional modules that can be subject to validation with occupational vocational training.

6.2 Professional modules that can be matched with work practice.

6.3 Access to University Studies.

1. Identification

1.1 Name: Health Documentation.

1.2 Level: higher-grade vocational training.

1.3 Duration of the training cycle: 1,400 hours.

2. Reference to the production system

2.1. Professional profile.

2.1.1 General Competition.

The general professional qualification requirements of the production system for this technician are:

Define and organize processes for the treatment of information and clinical documentation, codifying it and ensuring compliance with the standards of the health administration and the classification and coding systems international, under the relevant supervision.

2.1.2 Professional skills.

-Organize the clinical documentation of a care unit, applying health legislation regarding data confidentiality and developing and implementing the Information Security Plan of the documentation unit clinical, ensuring the flow of information between the different units/services.

-Define and/or interpret file system criteria, processes, and procedures.

-To analyze the needs of clinical documentation and the treatment of the information of the different units, defining according to them the structure of the documents that satisfy those needs.

-Apply quality assessment and control techniques for the information transmission systems between the different services/units, verifying and ensuring the compatibility of the formats adopted with those of the services that are related to the optimization of the aforementioned flow of information.

-Interpret and encode data from clinical documents, classifying specific diagnostic and therapeutic procedures.

-statistically use the information stored in the database.

-To participate in the development of new techniques, in research projects and in training programs, as well as to propose measures related to efficiency and safety.

-Poseer a comprehensive and integrated vision of the healthcare system in its organizational, functional, social and administrative aspects.

-To have an integrated view of the work to be done, adapting to the new situations generated as a result of technological and organizational innovations introduced in your work area.

-Collaborate with the members of the work team in which they are integrated, assuming their responsibilities, meeting the assigned objectives and maintaining the right information flow.

-To value the interrelation of people with health/disease and its preventive, care and rehabilitation aspects.

-Responding to contingencies, proposing solutions and solving problems that have arisen in the performance of work.

Requirements for autonomy in work situations:

This technician is called upon to act under the general supervision of technicians and/or senior professionals to his/her, providing you with the capabilities of autonomy in the:

Organization and management of the clinical documentation unit.

Determining file procedures.

Filming, microfilming and document scanning.

Selection and extraction of non-clinical data from clinical documentation.

Selection and extraction of clinical data from clinical documentation.

Determination of clinical documentation coding operations.

Preventive maintenance/conservation of the equipment in your office.

2.1.3 Competition Units.

1. Organize/manage documentation files and medical records.

2. Define and/or evaluate the process of information processing and clinical documentation.

3. Identify, extract and encode clinical and non-clinical data from the health documentation.

4. Validate and exploit the data in the Minimum Basic Data Set (CMBD) using statistical, epidemiological and quality control tools.

2.1.4 Professional Realizations and Domains.

Competition Unit 1: Organize/Manage Clinical Records and Documentation Files

REALIZATION CRITERIA

1.1 Tell the location, the loan and the return of the medical history to the different clinical units requesting, complying with the rules of use of the file of the center. /-It has been verified that the application for medical history has been carried out in the appropriate model and with the correct degree of completion in order to be able to carry out its localization.

-The location of the clinical history has been performed through the "planning" of the file, taking into account its numbering, activity-passive membership and color identification or any other method of search, described in the procedures manual or the rules of the file.

-The loan of history has been affected, prior to registration of the number of history, reason and type of request, unit and person requesting it, checking that the history corresponds fully to the requested one.

-The distribution of the history to the applicant units has been carried out, after their placement in the means of transport used in each center, following the guidelines of order, time, place and form fixed in the regulations of the file.

-It has been proven that the return of the history to the file, by the requesting units, has been carried out at the time and in the place, order and conditions of reception fixed by the file in its regulations, registering the movement of entry, verifying their correspondence with the previous application.

-It has been reviewed, taking into account the confidentiality of the data, which in the received history are in perfect order and numbering all the documents that it includes, as it collects the manual of use of the medical records of the health centre.

-The deposit and placement of the story in the file has been done following the same "planning" and conditions indicated for its location.

1.2 To achieve the correct distribution and optimization of space for the storage of medical records. /-It has been extracted the non-moving clinical histories of the registry of entries and exits, in the period that each center considers opportune (in general 5 years), and/or those other stories that meet the criteria set by the center to be the liability ("exitus", patients from other areas and others), referring them to the liability under the conditions laid down in the rules of the file, taking into account the legislation in force.

-The elaboration of a report-proposal on the determination of the file's surface has taken into account:

The prospective study of the surface that will require the archive of medical records, within the time that the center deems appropriate.

The volume of stories.

The archiving method.

The amount of annual openings for new stories.

Availability and access to information.

The optimization of the file space.

The confidentiality of the data.

The current legislation.

The indications that are collected in the center's regulations.

1.3 Define/establish the file method that optimizes the treatment of information and the use of resources, in the framework of the economic objectives assigned. /-In each case, the archiving method best suited to the document type and the space needs of the file is selected.

-The selected method responds to the availability of material resources and the allocated economic envelope, taking into account the instructions received.

1.4 Archive clinical histories and annexes, correctly applying the appropriate technique for different types of documents. /-The archiving technique; scanning, microfilming or other technologies has been selected taking into account the indications of use of each method.

-The selected technique is applied successfully handling the different equipment, and assessing the quality of the resulting record.

1.5 Control and evaluate the archive and storage of the medical records for the correct preservation, reliability, validity and manageability of the data. /-All conditions of fire safety, prevention of sinks, lighting, humidity and ventilation are known and fulfilled in the regulations for the use of the archive and the preservation of medical records.

-The Computer Security Plan is applied to ensure the security of the stored data, establishing measures that prevent the alteration, loss or cancellation of the data and its treatment or unauthorized access, taking into account Account:

The state of the technology.

The nature of the stored data.

The risks to which they are exposed, whether they come from human action or from the natural environment.

-Clinical case localization samples have been sampled to detect placement errors and evaluate the management of the file.

-Inventory, stock, and control of inputs and outputs have been monitored to assess the degree of correspondence with the current status of the file.

-Purge the database by extracting the stories that are duplicated and are being claimed, to the requesting units, those stories that have not been returned within the maximum deadline set by the file for the use of the medical records.

-The cost of managing the file is assessed and viable solutions are proposed that cover costs.

PROFESSIONAL DOMAIN

a) Production media: file area.

b) Treatment of information: computers. "Software" applied and databases. Manual and computer recording systems and supports (Optical disk, magnetic disk, floppy disks, filers, microfilm tab). Microfilmed and scanned documentation systems.

c) Results and/or products obtained: established file methods. File surface evaluated. The cost of managing the evaluated file. File sorted, updated and controlled.

d) Processes, methods and procedures: classification and updating procedures. File techniques. Documentation control techniques. Microfilmed and scanned techniques.

e) Information: adapted documentation flow systems. Systems adapted from file systems. Legal requirements for the preservation of documentation. IT Security Plan. Classification systems.

f) Personal and/or target organization: responsible for the file unit or clinical documentation. Administrative unit of the various clinical services. Administrative staff of the unit.

Competition Unit 2: Define and/or evaluate the processing of information and clinical documentation

REALIZATION CRITERIA

2.1 Standardize the general clinical documentation of the health center, for its correct homogenization, complying with the regulations established by the health center or company. /-The collection of the clinical-sanitary modelling of the centre has been carried out, taking into account:

Its validity and update.

The degree of use of each document.

Compliance with existing legislation.

-Proposals for new documents requested by the various health commissions are studied and valued, applying the existing regulations and the instructions issued by the clinical documentation officer.

2.2 Define the clinical documentation required to meet the operational objectives that are derived from its use. /-A new document has been defined, or modified the old one, in the form, type, receiver and other characteristics mentioned in the design protocols, manual of style and manual of procedures of the center.

-The clinical documentation elaborated meets the needs of the different services and units of the center and is adjusted to the indications of the responsible of the clinical documentation.

2.3 Validate, treat and evaluate the new clinical documentation to know if it meets the goal that prompted its design. /-The degree of satisfaction in the completion of the new document has been evaluated, after a period of implementation of the document, through the referral of a survey or questionnaire, prepared previously, and the study of the answers to it.

-The percentage of completion of the different items has been tabulated, with possible modifications.

-All parameters that for their form, layout type, data, size or other factor require changes have been corrected.

2.4 Intervening in the process of information processing. /-The flow of information between the different administrative units, clinical units and general diagnostic and treatment services is determined.

-The usefulness of the different documents is determined, by virtue of the planned itinerary and the type and characteristics of the data to be transmitted.

-Corrective measures are proposed in circuits, procedures or documents that optimize the flow or treatment of information.

PROFESSIONAL DOMAIN

a) Means of production and/or processing of information: computer. Graphic design software. Clinical documentation.

b) Results and/or products obtained: flow of information analyzed. Processing processes of the defined information. Defined and standardised clinical documentation. New models of documentation adapted to the objectives.

c) Processes, methods and procedures: documentation design techniques.

d) Information: clinical documentation needs of the different units. Hospital establishment plan.

e) Staff and/or target organisation: responsible for the clinical documentation unit. Commission of medical records. Clinical units. Administrative units.

Competition Unit 3: Identify, extract, and encode clinical and non-clinical data from healthcare documentation

REALIZATION CRITERIA

3.1 Code the non-clinical variables of the CMBD and those added by the center, following the procedure manual of the encoder established in the center. /-The list of pending coding stories has been obtained, comparing the database of the file and the computerization of the coding, according to the manual of procedures.

-The clinical histories pending coding have been requested from the different units, according to the rules of file and use of the medical history.

-It has been verified that all the minimum variables that must be extracted from the clinical history are found in the clinical report of high and clinical history.

-The minimum variables extracted from the clinical history, as basic data of the patient, are considered appropriate according to the current regulations.

-These variables have been incorporated which, at the center's discretion, have been requested to improve the care information systems and/or those that are reflected as advisable variables in the current regulations.

-The accuracy and degree of specificity of the data contained in the clinical report of discharge and/or clinical history, particularly the clinical data, has been proven.

-It is defined and obtained the complementary information necessary for the data encoding to be performed.

-Non-clinical CMBD variables have been coded by specific digits assigned, according to the definitions and regulations set out in the encoder procedure manual.

-Other non-clinical variables have been coded to collect the manual of the center, in the form and amount specified in it.

-All the non-clinical data of the CMBD have been introduced into the database software, destined for this purpose, in the form, mode, time and place that is collected in the regulations.

3.2 Identify the main diagnosis, according to the CMBD, by reviewing the clinical documentation and adjusting to the current regulations. /-The discharge report and the rest of the documentation of the medical history have been reviewed, if necessary, obtaining the diagnoses assigned by the physician.

-The main diagnosis, among the assigned diagnoses, has been identified, proving that the selected diagnosis is the one that, once the patient was studied, originated the entrance.

3.3 Identify other diagnoses according to the CMBD rules and current legislation. /-It has been proven that the identified diagnoses correspond to pathological processes, which are not the main diagnosis, and which coexist with the same at the time of admission, or which are developed throughout the hospital stay, or they are in the duration of the same or in the administered treatment.

-The diagnoses related to a previous episode have been excluded and have no relation to the one that has caused the current hospital stay, nor do they influence their evolution or increase the necessary resources.

3.4 Identify the diagnostic procedures applied in the patient/client study. /-All data on complementary scans performed on the patient to determine their diagnosis have been identified and extracted from the clinical history.

-It has been proven which of these tests or complementary explorations are directly related to the current process, to be used to reach the same or to rule out other possible diagnoses.

3.5 Identify the surgical procedures to which the patient/client has been subjected during his/her stay in the hospital. /-Data on surgical interventions performed on the patient have been identified and extracted, identifying the path, operation performed, taking biopsies and closing the track.

-All complications arising in the pre or post-operative period have been identified, assessing the relationship between them and the intervention.

-Normal delivery assistance has been coded as manual care delivery, followed by the episiotomy code if any.

3.6 Identify the obstetric procedures applied for the study/treatment of the patient/client in the various consultations and/or during their stay in the hospital. /-All the incidences, indicated in the medical history, have been analyzed during pregnancy, childbirth and postpartum, discarding all those that are not of interest for the coding.

-All of the obstetric incidences that occurred to the patient have been extracted: pregnancies, deliveries, abortions, obstetric complications.

3.7 Identify therapeutic, non-surgical procedures employed in the treatment and/or rehabilitation of the patient/client. /-Non-surgical therapeutic procedures (radiotherapy, electrotherapy, ultrasonotherapy, rehabilitation, chemotherapy) have been extracted and selected from the clinical history.

3.8 Define the data needs that complete the clinical history for the coding process. /-The data necessary to encode the clinical variables of the CMBD are determined and the collection of the same is ensured, using the appropriate channels of information flow.

3.9 Coding diagnoses ("main" and "other") and diagnostic, obstetric and surgical procedures, according to the international classification system of clinical modification-clinical modification in its last available review. /-Has been identified in each diagnosis the key element that allows its coding: pathology, adjective, name of the disease, eponimo or cause of income, being located later in the alphabetical index.

-The terms modifying the main term: non-essential and essential (anatomic place, etiology, clinical type and terms found in alphabetical order under the main term) have been identified in each diagnosis. and followed the instructions in the alphabetical order regarding cross-references, notes, and secondary codes.

-The disease has been classified according to the chapter, section, category, subcategory and subclassification of the tabular list, assigning the codes that best represent or best describe the classified diagnostic expression, the classification of diseases and injuries.

3.10 Identify the adverse effects produced by drugs, as well as the type of drug, differentiating between adverse reaction and intoxication. /-It has been previously differentiated if it is an adverse reaction or poisoning and the circumstance in which it has occurred:

accident.

Homicide.

Attempt to commit suicide.

Therapeutic use.

Undetermined.

-If this is an intoxication, the code for the poisoning and the code "E" that identifies the drug and the circumstance in which the poisoning has occurred has been located in the drug table. The manifestation of the poisoning has been coded as a secondary diagnosis.

-When it comes to an adverse reaction, the code that identifies the manifestation of the same, which will be the main one, has been located. Subsequently, the code "E", which identifies the drug causing the reaction, has been located in the therapeutic use column of the drug table.

3.11 Classifying neoplasms according to the CIE-MC norms and the histological type thereof. /-The histological (main) term has been located in the CI-MC, where the neoplasms are classified by system, organ or anatomical site, except for some neoplasms that are classified according to the tissue of origin (tumors lymph, haematopoietic, melanomas, lipomas and other tumors of the bone, uterus and ovary, and the corresponding code has been recorded.

-The essential term describing the anatomical site of the neoplasm and annotated the corresponding code has been located.

-The assigned codes specify the place of origin (primary, secondary), the behavior (malignant, benign, other) and the histological type of the encoded neoplasm.

3.12 Codify obstetric procedures, previous or pregnancy-related diseases and possible obstetric complications. /-The care episode in which the patient is located has been identified, assigning the patient the "5th digit".

-All diseases, previous or acquired during pregnancy, have been coded, which complicated this or aggravated their process.

-Complications arising from abortion have been codified, taking into account whether they have occurred within the same income or if the complication has resulted in a new income.

3.13 Codify AIDS and all its manifestations, identifying the stage of the disease according to the terminology of the clinician. /-In the coding of AIDS, its manifestations and clinical stage has been used the multiple classification.

-All manifestations of the disease have been localized and the medical history has been revised to analyze whether they are due to HIV infection or whether they are simply associated with it.

-The correct code identifying HIV infection has been selected, depending on the relationship between the manifestations and the infection, and depending on the manifestations the patient has suffered in previous income.

3.14 Classifying and coding specific diagnostic and therapeutic procedures. /-The access and closure routes in a surgical procedure have been coded only in cases where the surgery has not included the route or the normally used closure.

-Endoscopy has been encoded as a secondary code, when the procedure has been performed using the same and the diagnostic expression of the procedure classification does not include the same. Endoscopy refers to the last structure reached, in the case that it has been through several structures.

-Biopsies performed by endoscopy, uncut percutaneous percutaneous, and brushing biopsies will be coded as closed.

-They will be coded as open biopsies, only those made with diagnostic purpose, as well as intraoperative ones.

-The following are classified and encoded as miscellaneous diagnostic and therapeutic procedures:

Radiology.

Evaluations and tests.

Interviews and consultations.

Radiation Therapy.

Extracts.

Microscopic examinations.

-Microscopic examinations have been classified by anatomical location and assigned a fifth digit indicating the type of examination (bacterial smear, culture, culture and sensitization, parasitology, toxicology, cell block). and Pap smear, other microscopic examinations)

-The intended and unrealized procedures have been classified in the diagnosis with category V64, as a secondary code.

-Incomplete procedures have been coded following the following rules:

If only incision was made, it will be coded according to the site.

If the expected end of the procedure was not met, it will be encoded as performed.

If the cavity was accessed, it will be encoded as a site scan.

PROFESSIONAL DOMAIN

a) Information processing: computer. Software. Clinical stories. High reports. Death certificates. Paper or computer support. Databases. Coding tab.

b) Results and/or products obtained: clinical and non-clinical data of the identified and coded C.M.B.D.

c) Processes, methods and procedures: Coding procedure non-clinical data of the C.M.B.D. Regulations for the codification of health administration. Diagnostic procedures. Non-surgical therapeutic procedures. Obstetric procedures. Surgical procedures. Coding procedures.

d) Information: CIE-MC. C.M.B.D. D.S.M. Manual of Coding of the C.M.B.D. Surgical Procedures. Obstetric procedures. Specific diagnostic procedures (clinical analyses, cytological and pathological examinations, radiological and ecographic protocols). Medical treatment procedures. Diagnostic test reports: clinical analysis, X-rays, mammograms, MAH, R.M.N., ultrasound, cytological or anatomopathological studies of smear and biop sias, E.C.G., Doppler, cardiorespiratory function tests, E.M.G. and function tests muscle, E.G. and neurological function tests, ophthalmoscopic studies, audimetrical studies, allergic contact sensitivity tests, or intradermorreaction (Mantoux test).

e) Staff and/or target organisation: responsible for the clinical documentation unit.

Competition Unit 4: Validate and exploit the data from the minimum basic data set (C.M.B.D.) by means of statistical, epidemiological and quality control tools

REALIZATION CRITERIA

4.1 Determine the conditions for performing the quality control of the database. /-The quality control of the data is carried out before proceeding to the exploitation of the database.

-The methodology selected for evaluation and audit, corresponds to the guidelines set by the documentation unit responsible and takes into account the recommendations issued by the steering committee of the C.M.B.D.

-When carrying out the audit, it is systematically and in time defined.

4.2 Select a representative sample of the database to validate. /-The number of clinical histories to be reviewed is determined based on the size of the database, assigning a number to each clinical history and selecting the clinical histories using a random number table.

-A sample is extracted from the database, each time, to compare this information with the one in the clinical history.

4.3 Recode the clinical histories extracted from the database. /-The clinical histories extracted from the database are recoded again by a person other than the one who performed the first encoding, if possible.

-The data contained in the database, corresponding to the clinical histories of the selected sample, are extracted from the database.

4.4 Compare existing data in the database with those obtained in the new encoding. /-The coding resulting from the review with the initially assigned is compared, the existing discrepancies are detected, both in the clinical data, as in the non-clinical data, and are reviewed these determining and/or locating the error.

-It is determined whether the errors in the encoding of the clinical data have occurred in the main diagnosis or in the secondary diagnosis, if they are of diagnostic or encoding omission, in which case it is specified if the error is located at the category, subcategory, or subclassification level.

-Validation programs of the C.M.B.D. information are used and, based on this information, the appropriate changes are made to the database, the evaluation of all the data in the database is performed before sending the information to the central services.

4.5 Generate the most appropriate information to meet the needs of the health center, from the point of view of planning, management, or clinic. /-The information demanded by the managers and clinicians and the instructions marked by the person responsible for the unit is taken into consideration when generating the operation.

-The needs and demands of system users are determined through queries, surveys, or meetings.

-The information used in other centres is taken into account and recommended by the central bodies.

PROFESSIONAL DOMAIN

a) Information processing: computer. Databases. Manual recording media or computer media. Validation programmes of the C.M.B.D. Statistical packages.

b) Results and/or products obtained: quality control of the database. Exploitation of the database.

c) Processes, methods and procedures: statistical methods. Quality control procedures for database information.

d) Information: databases. Clinical stories. Recommendations of the steering committee of the C.M.B.D. Demands for information from the database.

e) Staff and/or target organization: Head of the clinical documentation unit.

2.2 Evolution of professional competence.

2.2.1 Changes in technological, organizational and economic factors.

To optimize health resource management, you need to know at all times what and how they are used. This makes it necessary to control the health processes and procedures, which is based on information about patients, their health care needs, hospital frequency, hospital stays per process and others. Health indices which can be determined by analysing and assessing the health benefits carried out. The coding of the medical records allows us to know the number and quality of the assistance provided and to deduce the actual expenses generated by what are foreseen organizational changes aimed at covering this plot of activity.

The implementation of the codification is not a temporary event, but an activity that will progressively increase to other areas of health, producing an increase of the qualified personnel to carry it out.

2.2.2 Changes in professional activities.

The growing need to know the real cost of health benefits is encouraging the implementation of the codification of the minimum basic data set (C.M.B.D.) by the public and private health network of the country. The realization of the C.M.B.D. entails the coding of the medical records, not only in terms of their administrative data, but also in the clinical ones.

It will be necessary for the information stored in the databases to be validated, exploited and used, generating the listings and information demanded by both the Health Administration and the management and the clinical units. of the health centre.

The coding activities will be affected by successive reviews of the international classification of diseases and injuries, with the continuous adaptation of these technicians being necessary.

2.2.3 Changes in training.

A higher degree of training is required in:

File techniques, filming and microfilming of documents, allowing to reduce spaces for the preservation of clinical documentation and greater functionality in the management of files.

Informatics: use of computer bases, design of documents by computer.

Classification and coding of diagnostics and procedures.

the absence of studies aimed at covering this important area of activity, the hospitals have had to resort to the staff who, with fewer hours of training, could assume this role, in the majority of the of the cases of graduates in nursing who, when they have prior health training, have only required specific training in codification.

The emergence of the new Senior Technical Health Documentation invests the relative weight of the training aspects mentioned above and optimizes and guides the combination of the same by adapting the training to the required competence in employment.

2.3 Position in the production process.

2.3.1 Professional and work environment.

This professional will be able to carry out his professional activity in the healthcare sector, in the area of health care and health promotion, in specialized care and in public health.

The main subsectors in which you can develop your activity are:

Primary and community care:

Archives of medical records.

Specialized attention:

Admission service.

Archives of medical records.

Public health:

Quality assessment and control area.

Epidemiology.

The Health Documentation Technician is hierarchically dependent on the optional person responsible for the clinical documentation unit or file of medical records.

2.3.2 Functional and technological environment.

The Healthcare Documentation Technician is located in the functions/subfunctions of organization/management of the unit of work, service delivery and quality control.

Technology skills and techniques include:

Organization and resource management of your work area.

Computer documentation design techniques.

filming techniques, microfilming and documentation scanning.

File Techniques. Procedures for the classification and updating of information.

Knowledge of anatomy, physiology and human pathology.

Knowledge about disease classification procedures.

Knowledge of non-surgical diagnostic and therapeutic procedures.

Knowledge of surgical and obstetric procedures.

Coding technique and procedure.

Computer science and database management skills.

Knowledge of epidemiology and statistics applied to health.

Health legislation.

Knowledge of the functional relationships and the "circuits" of the health information process.

Occupations, most relevant type jobs:

For example, and especially for the purposes of career guidance, a set of occupations or jobs that could be performed are listed below, acquiring the professional competence defined in the title profile.

Healthcare documentation technician.

Encoding technician.

Clinical documentation units.

Archives of medical records.

Quality assessment and control of healthcare delivery.

3. Minimum teachings

3.1 General objectives of the training cycle.

Use general computer packages, adapting them to the organization, management and treatment of the clinical and administrative information of a health center.

To analyze the organic and functional structure of the centers/services/units of the health sector and the current regulations regarding safety, hygiene and clinical-administrative documentation.

Analyze the characteristics of a clinical documentation file and the process of managing it, applying file management quality programs that allow for optimization of a center's documentary resources health.

Evaluate the process of processing information and the documentary needs of a healthcare facility, defining documents that adequately address these needs.

Analyze the clinical documentation, making the selection, extraction and coding of clinical and non-clinical data of the same.

To analyze databases and quality programs applied, in order to perform the exploitation and quality control of the same.

Analyze and use operating systems and software processing of texts, spreadsheets, and graphical applications to optimize the management and exploitation of information.

Understand the legal, economic and organizational framework that regulates and conditions professional activity, identifying the rights and obligations arising from reactions in the working environment, as well as the mechanisms of job insertion.

Select and critically assess the various sources of information related to your profession, which allows you to develop your self-learning capacity and enable the evolution and adaptation of your skills (a) professionals in technological and organizational changes in the sector.

3.2. Professional modules associated with a competition unit.

Professional module 1: clinical file organization

Associated with Competition Unit 1: Organize/Manage Clinical Records and Documentation Files

TERMINAL CAPABILITIES/ASSESSMENT CRITERIA

1.1 Analyze the process of archiving of clinical histories, relating their methods, phases and operations with the objectives, variables and conditions that allow to optimize the flow and determine the situation of the information. /To describe the health organization of type centers, both primary care and specialized.

Explain the processes of localization, loan, return and archiving of medical records.

Describe the rules of the clinical history archive.

Describe the criteria for identifying the real situation of a medical history.

In the case of practical application, loan, localization and archiving of clinical histories conveniently characterized:

Determine whether requests for medical records have been made in suitable conditions.

Select the most appropriate procedure to search and distribute the medical records.

Identify the medical records that have not been returned according to the regulations and proceed as determined.

Classify the provided clinical histories according to the conventional archiving system and the terminal digit.

1.2 Analyze the characteristics of a clinical documentation file to respond to the documentary needs of a healthcare facility. /List the criteria for the activity of the clinical documentation.

Describe the growth indicators of the medical records.

Explain the types of clinical files and their usefulness.

Explain the numerical archiving methods of clinical histories, relating them to the document type and space needs.

Describe archiving teams, their features, benefits, and drawbacks.

Explain archiving techniques: scanned and microfilmed documents.

In a scenario of organizing a properly characterized file:

Identify the passive documentation for the file.

To determine the growth of medical records in one year.

Evaluate and determine the space needs in the file.

Define the "planing" of the file.

Select, apply, and evaluate the quality resulting from the archiving technique.

Retrieve a microfilmed or scanned document in reader and paper.

Represent a plant distribution of the file by indicating the various areas and the flow of information.

1.3 Analyze the file management quality programs of a center, selecting the protocol to follow in each case. /Explain the characteristics of a file quality program

List the file quality indicators.

Describe common-use quality standards in clinical files.

Describe the criteria that allow you to locate errors in the archive.

In a practical scenario of quality control of a clinical file properly characterized operating correctly with a computer package for:

Detect duplicates of clinical histories and determine what are the most frequent errors.

Determine the location error rate.

Determine the index of archive errors.

Determine the index of out-of-file clinical histories.

BASIC CONTENTS (duration 90 hours)

(a) Health Organization: Health Organization.

b) Organization and management of clinical files.

c) Archive equipment and equipment.

d) Active/passive documentation: regulations and criteria.

e) Estimating space needs in a clinical file.

f) Archive techniques.

g) Quality programs in clinical files.

h) Clinical file security. Regulations in force.

Professional module 2: definition and treatment of clinical documentation

Associated with Competition Unit 2: Define and/or evaluate the process of processing information and clinical documentation

TERMINAL CAPABILITIES/ASSESSMENT CRITERIA

2.1 Analyze and evaluate the documentary needs of a healthcare facility, pointing out the technical mechanisms that

enable the logical and structured design of health documents. /To describe the types of documents of common use in health centers indicating their functionality.

Describe the types and functions of the medical history.

Describe the discharge report.

Explain the techniques of documentary design and its most characteristic applications.

Describe the characteristics of the materials for the realization of documents: dimensions, gramage and quality.

Explain the methods of estimating the consumption and cost of a document.

In a convenient documentary design scenario conveniently characterized:

Design your structure.

Select the document material.

Check that the document adapts to health and center regulations.

2.2 Analyze the technical parameters that check the utility of a health document. /Describe the methods of evaluation of documentation, explaining its characteristics, application, advantages and limitations.

Explain the items to include a survey or study of satisfaction, describing the areas of interest to be covered and the number of items needed for this.

Define the sampling point selection procedures.

Analyze the degree of completion of the submitted documents and propose modifications.

In a convenient scenario of clinical documentation evaluation conveniently characterized:

Define the degree of fulfillment of the different fields or sections, differentiating by units, professionals, or other variables.

Define and work out the satisfaction survey.

Select the survey sampling points appropriately.

Define the survey evaluation parameters and evaluate the data obtained.

2.3 Analyze the treatment process for the health center information. /Explain the flow of information between the different administrative units, clinical units and general diagnostic and treatment services.

In a practical scenario, from a properly characterized healthcare center:

Identify the types of documents that specify the information that should circulate for the operation of the center.

Determine the most relevant information flows between the various units and services.

Establish the process of processing information that optimizes administrative resources or treatments and the circulation of information.

Flow of information in healthcare facilities

Methods to optimize the treatment of information.

b) Documentary design.

c) Clinical documentation assessment methods.

d) Methodology of surveys and information processing.

BASIC CONTENTS (duration 70 hours)

a) The process of treating health information:

Clinical documentation: primary and secondary documents.

Clinical history.

Professional module 3: Encoding of clinical and non-clinical data

Associated with Competition Unit 3: Identify, Extract, and Encode Clinical and Non-Clinical Data in Healthcare Documentation

TERMINAL CAPABILITIES/ASSESSMENT CRITERIA

3.1 Analyze and extract the clinical data from the health documentation for coding. /Explain the information retrieval system and describe the phases of the documentary process. Define the concept of documentary profile and explain the documentary profile of the medical history, according to the C.M.B.A. or other indications.

Describe the variables of the C.M.B.D., explaining the criteria that define each of them.

Explain the concept, foundation, utility, and applications of coding.

Explain the main concepts and terms used in general pathology and disease classifications.

Relate the main signs, symptoms, and complications to the pathologies of different devices and systems.

Describe the criteria that determine the main diagnosis.

Describe the criteria that define secondary diagnosis, pathological diagnosis, and other types of diagnosis.

Explain the characteristics that define comorbidity, complication, personal history and family history.

Describe the applications of the main diagnostic procedures, relating them to the associated pathologies.

Differentiate between adverse drug reaction and intoxication.

Relate the main surgical and non-surgical therapeutic procedures to the different pathologies.

Describe the physiological patterns and main complications of pregnancy, childbirth and puerperium.

In a scenario of selecting and extracting clinical data, identify:

The reason for income.

The primary diagnosis.

The secondary diagnostics.

The diagnostic procedures used.

Surgical and non-surgical procedures.

3.2 Analyze and apply the criteria for coding of clinical data, selecting the procedure for the coding of the different diagnoses and procedures. /Explain the systems of classification of diseases and injuries, their structure and their main characteristics.

Explain the classification systems of surgical and non-surgical procedures.

Explain the basic coding process with the CIE-9MC, or with the latest encoding in effect.

In coding with CIE-9-MC, explain the specific coding rules:

Of tumors.

Of pregnancy, childbirth and puerperium.

Of sequels and complications.

From HIV infection.

Explain codes E and V codes

Describe the type of non-surgical procedures to be coded, according to the C.M.B.D.

In a practical case of clinical data encoding, code correctly:

The primary diagnosis.

The secondary diagnostics.

Surgical and non-surgical procedures.

BASIC CONTENTS (duration 170 hours)

a) Information retrieval systems.

b) C.M.B.D.

c) General pathology notions.

d) Classification of diagnostics.

e) Complications.

f) Non-surgical diagnostic and therapeutic procedures.

g) Obstetric procedures.

h) Surgical diagnostic and therapeutic procedures.

i) External causes of injuries and poisonings.

j) Classification systems for diseases and injuries.

k) Systems of classification of surgical and non-surgical procedures.

l) Basic coding procedure with CIE-9-MC.

m) Specific coding rules with CIE-9-MC.

Professional module 4: Validation and exploitation of healthcare databases

Associated with Competition Unit 4: Validate and exploit C.M.B.D. data using statistical, epidemiological, and quality control tools

TERMINAL CAPABILITIES/ASSESSMENT CRITERIA

4.1 Analyze the quality programs of clinical databases, selecting the appropriate protocol for each case. /Explain the procedures for debugging the databases.

Explain the quality programs of clinical databases.

Explain the quality programs of the coding of diagnostics and procedures.

Explain the recommendations for quality control issued by the C.M.B.A. steering committee

Define the concept of random sample and describe its selection process.

Explain the errors that can be encountered when evaluating a database, relating these to its causes, describing the type of error and the level and phase of the process in which it occurred.

In a practical scenario of quality control of a properly characterized clinical database:

Determine the size of the sample.

Select the sample.

Determine the quality program to be applied.

Apply the selected program.

Detect errors.

Develop quality indicators.

4.2 Analyze user information needs by determining the search profile. /Explain the selection criteria of the "search profile".

Describe the regulations governing the exploitation of clinical, administrative and statistical data.

Explain the characteristics and criteria that delimit professional secrecy, responsibility and data confidentiality.

Explain the foundation and application of the main health indicators (average stay, turnover rate, occupancy rate).

Explain the foundation and applications of the types of graphical data representation and describe the computer programs applied.

In a convenient information retrieval scenario conveniently characterized:

Draw up the search profile to demand for information.

Determine the center occupancy rate.

Determine the rate of rotation of a service.

Determine the average stay of patients who have been admitted for the same pathology.

Plot the extracted data.

BASIC CONTENTS (duration 80 hours)

a) Databases:

Database types.

Database design.

Using databases.

b) Evaluation of the quality of databases.

c) descriptive statistics applied to the exploitation of health data.

d) Health indicators: average stay, turnover rate, occupancy rate.

e) Data confidentiality and professional secrecy.

f) Information retrieval: search profile.

3.3 Modular professionals.

Professional module 5 (transversal): general computer applications

TERMINAL CAPABILITIES/ASSESSMENT CRITERIA

5.1 Interpreting the basic functions of the logical and physical elements that make up a computer system. /Explain the basic functions of the central processing unit and the peripheral equipment, relating them to the common phases of a data process.

Distinguish basic functions from internal memory, specifying the impact of their storage capacity on the capabilities of the computer system.

Classify peripheral equipment commonly used according to its function in the data processing.

Distinguish the basic characteristics of the different file supports commonly used in the personal computer segment.

Describe the general characteristics of some type models in the personal computer market.

Specify the concept of "byte" and define its multiples.

Define the program concept.

Specify the concepts of record and computer file.

Explain the concept of computing application and enumerate the type applications in business management.

From a practical case on a computer system that has installed "software" and its basic documentation, identify:

The "hardware" of the system.

The operating system and its features.

The system configuration.

Applications installed.

The information media used by the system.

5.2 Apply, as a user, the utilities, functions, and procedures of a single-user operating system. /Explain the structure, functions and basic characteristics of a single user operating system.

Install a single-user operating system.

Specify the command concept, distinguishing between internal and external commands.

Operating the computer equipment and verifying the various steps that take place by identifying the operating system load functions.

From practical assumptions: handle operating system utilities, functions, and procedures, justifying the syntax or, where applicable, the operating protocol.

Create files that handle operating system orders.

5.3 Apply the commands or instructions necessary for performing basic operations with a local area network connected system. /Describe the basic functions of the network server.

Explain the syntax relative to the basic commands and instructions of the network operating system.

In a scenario, perform, through the network operating system, copy, update, and transmit operations of the information previously stored on the server's hard disk.

5.4 Manage as a user a text processor and spreadsheet and apply procedures that ensure the integrity, security, availability, and confidentiality of stored information. /Distinguish, identify and explain the function of the applications: word processor and spreadsheet.

Properly install computer applications.

Access text processing applications and spreadsheets, through defined procedures.

From practical assumptions:

Handle the word processor, using the elementary functions, procedures, and utilities for editing, retrieval, modification, storage, integration ... of texts.

Handle spreadsheets using the elementary functions, procedures, and utilities for data processing.

Exchange data or information between text processing and spreadsheet applications.

Develop, copy, transcribe, and fill in information and documentation.

Back up application packages and managed information.

Justify the need to know and use periodically mechanisms or procedures for safeguarding and protecting information.

From case studies:

Interpret the security, protection, and integrity procedures that are set on the system.

Apply the above procedures from the operating system, from the "hardware" and/or from an application.

Detect failures in established and used security and protection procedures.

Argue and propose solutions.

BASIC CONTENTS (duration 55 hours)

a) Introduction to computing:

Data and computing processes.

Hardware items.

Peripheral equipment.

Internal data representation.

Software items.

b) Operating Systems:

Basic functions of an operating system.

Single-user and multi-user operating systems.

Using single-user operating systems: operating system commands.

User environment.

c) Local networks:

Basic types of local area networks.

Physical components of local networks.

Local network operating system.

d) Text processors:

Document Design.

Editing texts.

File management.

Printing of texts.

e) Calculation sheets:

Layout of spreadsheets.

Editing spreadsheets.

File management.

Printing spreadsheets.

f) Graphical and self-editing applications:

Types of supported charts.

Layout of charts.

Presentation of charts.

Integration of charts into documents.

g) Integrated packages:

Integrated package modularity.

Professional module 6 (transverse): relationships in the workbench

TERMINAL CAPABILITIES/ASSESSMENT CRITERIA

6.1 Effectively use communication techniques in your working environment to receive and issue instructions and information, exchange ideas or opinions, assign tasks and coordinate projects. /Identify the type of communication used in a message and the different strategies used to achieve good communication.

Classify and characterize the different stages of a communicative process.

Distinguish good communication that contains a clear message from another with divergent paths that disappear or entrenate the main objective of the transmission.

Infer the alterations produced in the communication of a message in which there is disparity between the emitted and the perceived.

Analyze and assess interference that makes it difficult to understand a message.

6.2 To address the conflicts that arise in the environment of their work, through negotiation and the achievement of the participation of all the members of the group in the detection of the origin of the problem, avoiding trials of value and resolving the conflict by focusing on those aspects that can be modified. /Define the concept and the elements of the negotiation.

Identify the types and effectiveness of possible behaviors in a negotiation situation.

Identify negotiation strategies that relate to the most common situations of conflict occurrence in the enterprise.

Identify the method for preparing a negotiation taking into account the collection phases of information, assessment of the relationship of forces and forecast of possible agreements.

6.3 Making decisions, contemplating the circumstances that require making such a decision, and taking into account the opinions of others regarding possible solutions. /Identify and classify the possible types of decisions that can be used in a particular situation.

Analyze the circumstances in which you need to make a decision and choose the most appropriate one.

Apply the search method for a solution or response.

Respect and take into account the opinions of others, even if they are contrary to their own.

6.4 Exercise leadership in an effective way within the framework of their professional skills by adopting the most appropriate style in each situation. /Identify the styles of command and the com portments that characterize each one of them.

Relate leadership styles to different situations where the leader can meet.

Estimate the role, competencies, and limitations of the intermediate command in the organization.

6.5 Driving, moderating and/or participating in meetings, actively collaborating or getting the participants ' collaboration. /List the advantages of the work teams against the individual work.

Describe the function and method of meeting schedule, defining, through simulated cases, objectives, documentation, order of the day, attendees, and convening of a meeting.

Define the different types and functions of the meetings.

Describe the different types and functions of meetings.

Identify the type of participants.

Describe the stages of meeting development.

List the most relevant objectives that are pursued in group meetings.

Identify the different techniques of dynamization and operation of groups.

Discover the features of the most relevant techniques.

6.6 Driving the motivation process in your work environment, facilitating improvement in the work environment and the commitment of people to the company's goals. /Define the motivation in the working environment.

Explain the great theories of motivation.

Identify the applicable motivation techniques in the work environment.

In simulated cases select and apply appropriate motivation techniques to each situation.

BASIC CONTENTS (duration 30 hours)

a) Communication in the enterprise:

Production of documents in which the tasks assigned to members of a team are contained.

Oral communication of instructions for the achievement of objectives.

Communication types.

Stages of a communication process.

Communication networks, channels, and media.

Difficulties/barriers in communication.

Resources for manipulating perception data.

The communication generating behaviors.

The control of the information. The information as a management function.

b) Negotiation:

Concept and elements

Negotiating strategies

Influence styles

c) Troubleshooting and decision-making:

Resolution of conflicting situations caused as a result of relationships in the workbench.

Process for troubleshooting.

Factors that influence a decision.

The most common methods for group decision making.

Phases in decision making.

d) Command Styles:

Address and/or Leadership.

Address styles.

Theories, approaches to leadership.

e) Driving/steering of work equipment:

Application of the techniques of dynamization and direction of groups.

Stages of a meeting.

Types of meetings.

Dynamics and group address techniques.

Typology of the participants.

f) The motivation in the work environment:

Definition of the motivation.

Main theories of motivation.

Diagnosis of motivational factors.

3.4 Vocational training module in the workplace.

TERMINAL CAPABILITIES/ASSESSMENT CRITERIA

Diligent the location, loan and return of medical records between the file and the applicant units, complying with the rules of use of the archive of the center's medical records. /Evaluate the application, determining the type (urgent, scheduled, study) and selecting the procedure indicated in each case.

Locate the requested clinical histories.

Make the loan of the medical records, registering the request unit, the requesting person, the reason for the application and all the variables that determine the procedure manual of the center.

Make the list of requested medical records and check that they correspond to those prepared for distribution.

Check the location of the pending coding records and, in case they are in a loan situation, claim them at the different units.

Check that the return of the clinical histories from the different units has been performed according to the rules of the file.

Review the returned clinical histories and check that the order and numbering of the documents is adapted to the rules of the center.

Proceed to the pre-archiving and archiving of the medical records.

Select the passive documentation from the clinical history file. /Identify, extract and send the passive documentation of the file.

Issue a list of clinical stories that have not been moved in a given period, extract them from the file and refer them to the liability.

Identify and extract the medical records that correspond to "exitus", to patients in other areas, or to patients with a certain disease.

Apply the file management quality programs. /Detect possible duplicates of medical records.

Detect possible clinical case localization errors.

Detect possible archiving errors.

Elaborate duplicate indexes, localization errors, archive errors, and out-of-file clinical histories.

Apply scanning and microfilm techniques and retrieval of documents recorded with these techniques. /Perform the microfilmed or scanned of medical records, assessing the quality of the results.

Save the microfilm to the "jaquet" and archive them.

Recover microfilmed or scanned stories on paper.

Encode non-clinical variables in the minimum basic data set (C.M.B.D.). /Identify non-clinical variables of the C.M.B.D. and those defined by the center.

Assign codes to the variables identified according to the regulations of the C.M.B.D. and the center.

Identify and extract diagnostics and procedures from the medical records. /Identify and select the primary diagnosis and secondary diagnoses (complications and comorbidities) assigned by the physician in the medical history.

Identify the causes that have caused an injury.

Identify any health problems or circumstances affecting the same and that should be selected according to the C.M.B.D.

Select the surgical procedures, identifying the path, the operation performed, the biopsy and the closure of the route, determining the main surgical procedure.

Identify and select non-surgical procedures, both diagnostic and therapeutic, in accordance with the regulations of the C.M.B.A. and the regulations of the center.

Encode diagnostics by international classification of diseases, 9. clinical modification (CIE-9-MC). /Select the main term that defines each diagnosis and identify the essential and non-essential modifiers that accompany it.

Locate the main term in the alphabetical index, by checking the code that provides that index in the tabular list.

Proceed to code assignment by following the alphabetical index, tabular list, and CIE-9-MC instructions, both general and chapter-specific.

Codify surgical and non-surgical procedures using CIE-9-MC. /Select the main term that defines the procedure and identify the essential and non-essential modifiers that accompany it.

Locate the main term in the alphabetical index, selecting the code taking into account the essential and non-essential modifiers and the technique used to perform the procedure.

Verify the code in the tabular list and assign the codes by following the instructions in the alphabetical index and the tabular list and the CIE-9-MC rules.

Perform selective retrieval of information for system users. /Evaluate the request for information and elaborate the most appropriate search profile.

Proceed according to the protocol of the center to retrieve the records according to the set profile.

Select samples from the database.

Locate the primary document.

Process the information again.

Elaborate the fulfillment indexes and the database concordance indexes.

Perform a particular search, assessing the noise and silence of the database.

Duration 240 hours.

3.5 Professional training and guidance module.

TERMINAL CAPABILITIES/ASSESSMENT CRITERIA

Determine preventive and/or protective actions by minimizing risk factors and the consequences for the health and environment they produce. /Identify the most common risk situations in their field of work, associating the general techniques of action according to them.

Classify the damage to health and the environment according to the consequences and the most common risk factors that generate them.

Propose preventive and/or protective actions corresponding to the most common risks, which will reduce their consequences.

Apply immediate basic sanitary measures at the site of the accident in simulated situations. /Identify the priority of intervention in the case of several injured or multiple injured persons, in accordance with the criterion of greatest risk of injury.

Identify the sequence of measures that should be applied based on the existing lesions in the previous assumption.

Perform health techniques (CPR, quiesce, move), applying established protocols.

Differentiate the hiring modalities and apply insertion procedures in the work reality as an employed or self-employed person. /To identify the different modalities of employment contracts in the productive sector that allows existing legislation.

In a given situation, choose and properly use the main job search techniques in your professional field.

Identify and properly fill in the necessary documents and locate the precise resources to be self-employed.

Orientate in the labour market, identifying their own abilities and interests and the most suitable professional itinerary. /To identify and evaluate the skills, attitudes and knowledge with professionalizing value.

Define the individual interests and their motivations, avoiding, where appropriate, the conditions for reasons of sex or other type.

Identify the training offer and the labor demand related to your interests.

Interpret the legal framework of the work and distinguish rights and obligations arising from industrial relations. /Use the basic information sources of employment law (Constitution, Workers ' Statute, European Union Directives, collective agreement) distinguishing the rights and obligations incumbent upon it.

Interpret the various concepts involved in a "business settlement".

In a class collective negotiation scenario:

Describe the negotiation process.

Identify variables (salary, security and hygiene, technological productivity) object of negotiation.

Describe the possible consequences and measures, as a result of the negotiation.

Identify social security benefits and obligations.

Interpret the data of the Spanish socioeconomic structure, identifying the different variables involved and the consequences of their possible variations. /From general economic information:

Identify the main macroeconomic measures and analyze the relationships between them.

Analyze the organization and economic situation of a company in the sector, interpreting the economic parameters that determine it. /Explain the functional areas of a company type of the sector, indicating the relationships existing between them.

From the economic memory of a company:

Identify and interpret the most relevant economic variables involved in it.

Calculate and interpret the basic ratios (financial autonomy, solvency, guarantee and financing of the fixed assets) that determine the financial situation of the company.

Indicate the company's possible funding lines.

BASIC CONTENTS (duration 35 hours)

a) Health care:

Working conditions and security.

Risk factors: prevention and protection measures.

Safe work organization: general prevention and protection techniques.

First aid.

b) Legislation and industrial relations:

Labour law: national and Community law.

Social Security and other benefits.

Collective Bargaining.

c) Sociolaboral orientation and insertion:

The job search process.

Initiatives for self-employment.

Analysis and evaluation of professional potential and personal interests.

Formative/professional itineraries.

Non-discriminatory social habits.

d) Principles of economics:

Macroeconomic variables and socio-economic indicators.

International socioeconomic relations.

e) Economics and organization of the company:

The company: functional areas and organizational charts.

Economic operation of the company.

3.6 Baccalaureate and other basic training contents:

3.6.1 Mode Materies:

Biology.

3.6.2 Other Base Training Content:

Osteology. Artrology. Myology:

General considerations.

skeleton constitution (osteology and myology):

Skull and face.

Spine.

Top member.

Lower member.

Physiology general.

Pathology most frequent.

Esplacnology: General Physiology and Pathology Most Common:

Respiratory system.

cardiocirculatory system. Digestive system.

urogenital apparatus.

Neurology.

Organs of the senses.

Central and peripheral nervous system.

Endocrinology.

4. Teachers

4.1 Teachers ' specific teaching assignments in the professional modules of the Health Documentation training cycle.

Professional Module/Teacher/Body Speciality

1. Organization of clinical files. /Health and care procedures. /Technical Teacher of Vocational Training.

2. Definition and treatment of clinical documentation. /Healthcare processes. /Secondary School Teacher.

3. Coding of clinical and non-clinical data. /Healthcare processes. /Secondary School Teacher.

4. Validation and exploitation of the health data bases. /Health and care procedures. /Technical Teacher of Vocational Training.

5. General computer applications. /Health and care procedures. /Technical Teacher of Vocational Training.

6. Relationships in the workbench. /Training and employment orientation. /Secondary Teaching Teacher

7. Training and career guidance. /Training and Employment Guidance. /Secondary School Teacher.

4.2 Baccalaureate materials that can be taught by the teachers of the specialties defined in this Royal Decree.

Teacher/Body Materials/Specialty

Biology. /Healthcare processes. /Secondary School Teacher.

4.3 Qualifications of qualifications for teaching purposes.

4.3.1 For the delivery of the professional modules corresponding to the specialty of:

Healthcare Processes.

The equivalence, for teaching purposes, of the title of:

University Diploma in Nursing, with those of Doctor, Engineer, Architect or Bachelor.

4.3.2 For the partition of the professional modules corresponding to the specialty of:

Training and employment orientation.

The equivalence, for the purposes of teaching, of the title/s of:

Diplomat in Business Sciences.

Diplomat in Labor Relations.

Diploma in Social Work.

Diploma in Social Education.

With those of Doctor, Engineer, Architect or Licensed.

5. Minimum requirements for spaces and facilities to impart these teachings

In accordance with Article 39 of Royal Decree 1004/1991 of 14 June 1991, the training cycle of higher-grade vocational training: Health documentation, requires, for the delivery of the teachings defined in the Royal Decree, the following minimum spaces which include those laid down in Article 32.1.a of the aforementioned Royal Decree 1004/1991 of 14 June.

Formative Space/Surface-m2/Utilization Grade Percentage

Multipurpose Classroom/60/45

Healthcare Documentation Classroom. /90/55

The "degree of utilization" expresses in so much percent the occupation in hours of the planned space for the imparting of the minimum teachings, by a group of students, regarding the total duration of these teachings and therefore, has a guiding sense for which educational administrations will define when setting up the curriculum.

In the margin allowed by the "degree of utilization", the established training spaces can be occupied by other groups of students who are cured the same or other formative cycles, or other educational stages.

In any case, the learning activities associated with the training spaces (with the occupation expressed by the degree of use) may be carried out on surfaces used for other related training activities.

It should not be interpreted that the different learning spaces identified must necessarily be differentiated by means of closure.

6. Convalidations, correspondences and access to university studies

6.1 Professional modules that can be subject to validation with occupational vocational training.

Organization of clinical files.

Coding of clinical and non-clinical data.

Validation and exploitation of health databases.

General computer applications.

6.2 Professional modules that can be matched with work practice.

Organization of clinical files.

Coding of clinical and non-clinical data.

Validation and exploitation of health databases.

Training and employment guidance

Job Center Training

6.3 Access to University Studies.

University Diploma in Nursing.

University Diploma in Physical Therapy.

University Diplomat in Podology.

University Diploma in Occupational Therapy.