Professional Documents
Culture Documents
TR Medical Coding and Claims Processing NC III
TR Medical Coding and Claims Processing NC III
ICT SECTOR
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Technical Education and Skills Development Act of 1994
(Republic Act No. 7796)
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The Training Regulations (TR) serve as basis for the:
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TABLE OF CONTENTS
ICT SECTOR
MEDICAL CODING AND CLAIMS PROCESSING
NATIONAL LEVEL III
Page No.
Basic Competencies 2 - 21
Common Competencies 22 - 29
Core Competencies 30 - 39
COMPETENCY MAP 58
DEFINITION OF TERMS 59 – 62
ACKNOWLEDGEMENT 63
0
TESDA-SOP-QSO-01-F08
This Qualification is packaged from the competency map of the Information and
Communication Technology Industry (Service sector) as shown in Annex A.
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This section gives the details of the contents of the basic, common, and core units
of competency required for MEDICAL CODING AND CLAIMS PROCESSING NC III.
BASIC COMPETENCIES
UNIT DESCRIPTOR : This unit covers the knowledge, skills and attitudes required
to lead in the dissemination and discussion of ideas,
information and issues in the workplace.
PERFORMANCE CRITERIA REQUIRED REQUIRED SKILLS
ELEMENT Italicized terms are elaborated in KNOWLEDGE
the Range of Variables
1. Communicate 1.1. Appropriate Organization Organizing
information communication method requirements for information
about is selected written and Understanding and
workplace 1.2. Multiple operations electronic conveying intended
processes involving several topics communication meaning
areas are communicated methods Participating in
accordingly variety of workplace
1.3. Questions are used to gain Effective verbal
discussions
extra information communication
Complying with
1.4. Correct sources of methods
organization
information are identified Methods of requirements for the
1.5. Information is selected and Communication use of written and
organized correctly electronic
Types of Question
1.6. Verbal and written communication
reporting is undertaken Communication methods
when required Tools Reporting
1.7. Communication skills are Questioning occupational
maintained in all situations Techniques hazards during
safety meeting
2. Lead 2.1 Response to workplace Leading as a Communicating
workplace issues are sought management effectively
discussions 2.2 Response to workplace function
Barriers of Consulting the crew
issues are provided
communication on the prepared
immediately
Effective verbal menu for the month
2.3 Constructive contributions
are made to workplace communication
discussions on such issues methods
as production, quality and Method/techniques
safety of discussion
2.4 Goals/objectives and How to lead
action plan are undertaken discussion
in the workplace are How to solicit
communicated response
Goal setting and
action planning
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RANGE OF VARIABLES
VARIABLE RANGE
1. Methods of 1.1. Non-verbal gestures
communication 1.2. Verbal
1.3. Face to face
1.4. Two-way radio
1.5. Speaking to groups
1.6. Using telephone
1.7. Written
1.8. Internet
EVIDENCE GUIDE
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RANGE OF VARIABLES
VARIABLE RANGE
1.1. Client Profile
1. Work requirements
1.2. Assignment instructions
2. Team member’s concerns 2.1. Roster/shift details
3.1. Formal process
3. Monitor performance
3.2. Informal process
4.1. Formal process
4. Feedback
4.2. Informal process
5.1. Work output
5. Performance issues
5.2. Work quality
5.3. Team participation
5.4. Compliance with workplace protocols
5.5. Safety
5.6. Customer service
EVIDENCE GUIDE
1. Critical aspects of Assessment requires evidence that the candidate:
Competency 1.1. Maintained or improved individuals and/or team
performance given a variety of possible scenario
1.2. Assessed and monitored team and individual
performance against set criteria
1.3. Represented concerns of a team and individual to next
level of management or appropriate specialist and to
negotiate on their behalf
1.4. Allocated duties and responsibilities, having regard to
individual’s knowledge, skills and aptitude and the needs
of the tasks to be performed
1.5. Set and communicated performance expectations for a
range of tasks and duties within the team and provided
feedback to team members
2. Resource The following resources MUST be provided:
Implications 2.1. Access to relevant workplace or appropriately simulated
environment where assessment can take place
2.2. Materials relevant to the proposed activity or task
3. Methods of Competency in this unit may be assessed through:
Assessment 3.1. Written Examination
3.2. Oral Questioning
3.3. Portfolio
4. Context for 4.1. Competency assessment may occur in workplace or any
Assessment appropriately simulated environment
4.2. Assessment shall be observed while task are being
undertaken whether individually or in-group
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RANGE OF VARIABLES
VARIABLE RANGE
1. Preparing for 1.1 Background information on other parties to the
negotiation negotiation
1.2 Good understanding of topic to be negotiated
1.3 Clear understanding of desired outcome/s
1.4 Personal attributes
1.4.1 self-awareness
1.4.2 self esteem
1.4.3 objectivity
1.4.4 empathy
1.4.5 respect for others
1.5 Interpersonal skills
1.5.1 listening/reflecting
1.5.2 nonverbal communication
1.5.3 assertiveness
1.5.4 behavior labeling
1.5.5 testing understanding
1.5.6 seeking information
1.5.7 self-disclosing
1.6 Analytic skills
1.6.1 observing differences between content
and process
1.6.2 identifying bargaining information
1.6.3 applying strategies to manage process
1.6.4 applying steps in negotiating process
1.6.5 strategies to manage conflict
1.6.6 steps in negotiating process
1.6.7 options within organization and externally
for resolving conflict
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EVIDENCE GUIDE
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RANGE OF VARIABLES
VARIABLE RANGE
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EVIDENCE GUIDE
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UNIT DESCRIPTOR : This unit covers the knowledge, skills and attitudes required
in the application of mathematical concepts and techniques.
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RANGE OF VARIABLES
VARIABLE RANGE
1. Mathematical techniques May include but are not limited to:
1.1 Four fundamental operations
1.2 Measurements
1.3 Use/Conversion of units of measurements
1.4 Use of standard formulas
EVIDENCE GUIDE
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RANGE OF VARIABLES
VARIABLE RANGE
1. Technology May include but are not limited to:
1.1 Office technology
1.2 Industrial technology
1.3 System technology
1.4 Information technology
1.5 Training technology
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EVIDENCE GUIDE
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COMMON COMPETENCIES
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RANGE OF VARIABLES
VARIABLE RANGE
1. Materials/components 1.1. Materials may include but not limited to:
1.1.1. wires
1.1.2. cables, soldering lead
1.1.3. electrical tape
1.2. Components may include but not limited to:
1.2.1. ICs
1.2.2. Diodes
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EVIDENCE GUIDE
2. Method of assessment 2.1. The assessor may select two (2) of the following
assessment methods to objectively assess the
candidate:
2.1.1. Observation
2.1.2. Questioning
2.1.3. Practical demonstration
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RANGE OF VARIABLES
VARIABLE RANGE
1. Hardware and peripheral 1.1. Personal computers
devices 1.2. Networked systems
1.3. Communication equipment
1.4. Printers
1.5. Scanners
1.6. Keyboard
1.7. Mouse
6. Desktop icons Icons include the following but not limited to:
6.1. directories/folders
6.2. files
6.3. network devices
6.4. recycle bin
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EVIDENCE GUIDE
2. Method of assessment 2.1. The assessor may select two of the following
assessment methods to objectively assess the
candidate:
2.1.1. Observation
2.1.2. Questioning
2.1.3. Practical demonstration
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CORE COMPETENCIES
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Client’s specific
guidelines/ coding
standards
Medical Documentation
Healthcare Laws and
Ethics
Essential of healthcare
insurance
Medical Coding Systems
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RANGE OF VARIABLES
VARIABLE RANGE
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EVIDENCE GUIDE
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Client’s specific
guidelines/ coding and
claims processing
standards
5S and 3Rs
2. Screen claims 2.1. Claims are checked for Medical Terminologies Analytical skills
authorization, eligibility Medical Documentation
based on provider and/or Reading and
Medical claim process
subscriber contract with comprehension
Healthcare Laws and
the payer skills
Ethics
2.2. Completeness of claims Essential of healthcare Researching skills
documentation are insurance Basic
checked in accordance Medical Coding Systems mathematical
with payer requirements o International skills
2.3. Lacking data based on the
Classification of Communication
initial screening result are
Diseases
requested from medical skills
o Current Procedural
provider Computer skills
Terminology
o Healthcare Common
Procedure Coding
System
Client’s specific
guidelines/ coding and
claims processing
standards
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RANGE OF VARIABLES
VARIABLE RANGE
1. Data May include but not limited to:
Patient information
Patient medical records
Record of medical provider
2. Claims processing May include but not limited to:
requirements General guidelines
Client-specific guidelines
3. Claims documentation May include:
1. medical report
2. supply documentation
4. Billing information May include but not limited to:
Diagnosis Code
Date of injury
Date of service
Place of service
Procedure and other service codes
Number of units
Charges
EVIDENCE GUIDE
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UNIT TITLE :
MANAGE MEDICAL CLAIMS
UNIT CODE :
ICT325303
UNIT DESCRIPTOR :
This unit covers the skills, knowledge and attitude necessary to
manage medical claims. It covers managing account
receivable, denials/ rejections and underpaid medical claims.
ELEMENT PERFORMANCE CRITERIA REQUIRED REQUIRED
Italicized terms are elaborated in KNOWLEDGE SKILLS
the Range of Variables
1. Manage 1.1. Processed and submitted Medical Terminology Analytical skills
account claims are tracked and o Systems of the body Reading and
receivable monitored based on (e.g., skeletal, comprehension
enterprise or client respiratory, skills
requirements cardiovascular) Researching
1.2. Pending claims are o Human anatomy skills
followed-up from payer o Human physiology Basic
and/or patient in o Fundamental nature of a mathematical
accordance with disease process, signs, skills
enterprise policy symptoms and methods Communication
1.3. Supporting documents of treatment skills
are Identified and o Common medical Computer skills
requested from the
conditions
medical provider based on
o Medical investigations
payer requirements (when
and procedures
necessary)
o Injuries
1.4. Posting of payments are
performed in accordance o Common abbreviations
with enterprise/client’s for medical and
policy pharmacological terms
(e.g., BCG, HRT)
o Common medications
o Commonly used medical
equipment and
instruments
o Laboratory testing
methods
o Diagnostic and surgical
procedures
o Laboratory values and
significance
o Medico-legal terminology
Medical Documentation
Medical claim process
Healthcare Laws and Ethics
Essential of healthcare
insurance
Medical Coding Systems
include but not limited to:
o Diagnosis code set
o Procedure code set
o Supplies Code set
Client-specific guidelines
and coding and claims
processing standards
5S and 3Rs
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RANGE OF VARIABLES
VARIABLE RANGE
1. Supporting documents May include but not limited to:
Patient’s record (diagnostic examination result)
Medical provider’s notes
Diagnoses code set, procedure code set and supplies
code set
Billing record
2. Posting of payments May be classified as:
fully paid
under paid
rejected or denied
3. Rejected claims May be caused by but not limited to:
Incomplete/incorrect patient information
Illegible/unreadable documents
Incorrect medical codes
Incomplete/incorrect providers information
4. Reasons for May include but not limited to:
underpayment Medically unnecessary procedure, supplies and/or
equipment
Not covered by benefit plan
Exceeded coverage plan
Unauthorized procedure, supplies and/or equipment
Duplicate billing
Bundled medical procedure codes
EVIDENCE GUIDE
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This set of standards provides Technical and Vocational Education and Training
(TVET) providers with information and other important requirements to consider when
designing training programs for Medical Coding and Claims Processing NC III.
Delivery of knowledge requirements for the basic, common and core units of
competency specifically in the areas of mathematics, science/technology,
communication/language and other academic subjects shall be contextualized. To this
end, TVET providers shall develop a Contextual Learning Matrix (CLM) to accompany
their curricula.
Course Description:
To obtain this, all units prescribed for this qualification must be achieved:
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BASIC COMPETENCIES
32 hrs
Unit of Learning Learning Content Practical Activities Assessment Nominal
Methodology
Competency Outcomes (Required Knowledge) (Required Skills) Approach Duration
1. Lead 1.1 Communicate Method of communication Expressing One self Group Written Test 2 hours
workplace information Communication skills Practice on Public speaking discussion Interview
communication about Communication tools Written activities on Role Play Observation
workplace Questioning techniques workplace process Brainstorming
processes. Demonstration
.
1.2 Lead Method/technique of Written and Electronic Self-paced Written Test 2 hours
workplace discussion communication activities handout/ Demonstration
discussions How to lead discussion Debate Exercises module
How to solicit response Discussion
Role Play
1.3 Identify and Identify problems and Resolving conflict in the Brainstorming Interviews 2 hours
communicate issues workplace Self-paced Written exam
issues arising Organizing information on Making a report about handout/ Demonstration
in the problem and issues problem and issues module
workplace Relating problems and Practice communication Role Play
issues model Self-paced
Communication barriers handout/
affecting workplace module
discussions
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2.2 Assign Duties and responsibilities Planning session regarding Role Play Case studies 2 hours
responsibilities of each team member duties and responsibilities of Workshop Interview
among Skills in identifying each team member Demonstration Demonstration
members individual skills, knowledge Writeshop of interpersonal
and attitude as basis for abilities, attitude and
allocating responsibilities knowledge
Knowledge in identifying Identification of team
each team member duties members responsibilities thru
and responsibilities simulation
2.3 Set Knowledge and skills in Develop /implement an Group Written exam 1 hour
performance setting individual appraisal document for the discussion Demonstration
expectation for performance worker Writeshop Written Exam
team target/expectation Workshop on setting Multimedia
members. Team members duties and individual performance target presentation
responsibilities Writeshop on team members
Employee policies and duties and responsibilities
procedures Video presentation regarding
Defining performance employees performance role
expectations criteria and expectation towards
work
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32
hours
Note: Basic competencies may be embedded in the core competencies.
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COMMON COMPETENCIES
18 hrs
1.2 Assess own 2.1 Safety and environmental Observing safety Field trip Demonstration & 3 hours
work aspects of production and environmental Symposium questioning
processes aspects of Film showing Observation &
2.2 Fault identification and production Simulation questioning
reporting processes On the job training Third party report
2.3 Workplace procedure in Preparing technical
documenting completed reports
work Performing
2.4 Workplace Quality procedures in the
Indicators workplace
1.3 Engage in 3.1 Quality improvement Implementing Field trip Demonstration & 2 hours
quality processes continuous Symposium questioning
improvement a. IEC/ISO standards improvement Film showing Observation &
b. Environmental and Simulation questioning
safety standards On the job training Third party report
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2.2 Input data into 2.1 keyboard and computer Encoding of data Modular Demonstration & 1 hour
computer user Saving encoded Film showing questioning
data Computer based Observation &
2.2 Storage devices and
training (e-learning) questioning
basic categories of
Project method Third party report
memory
On the job training Assessment of
2.3 Relevant types of output product
software Portfolio
Computer- based
assessment
2.3 Access 3.1 General security, privacy Accessing computer Modular Demonstration & 2 hours
information legislation and copyright data/files Film showing questioning
using computer 3.2 Productivity Application Performing data Computer based Observation &
Microsoft office encoding training (e-learning) questioning
applications Creating Project method Third party report
3.3 Business Application presentation On the job training Assessment of
Introduction to Basic materials output product
Programming software Drafting office Portfolio
communication and Computer- based
documents assessment
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CORE COMPETENCIES
160 hrs
Unit of Learning Assessment Nominal
Learning Contents Practical Activities Methodologies
Competency Outcomes Methods Duration
1. Assign 1.1 Prepare Types and contents of Analyzing the completeness of a Lecture Written exam 16
Medical requirements medical record medical record Discussion Demonstration
Codes for medical Different type and uses of Demonstration Interview
Identifying different types of
coding Medical Codes medical codes and its uses
Identification of types and
Identifying types of Coding Tools
uses Coding Tools
Format and Organization of Familiarizing on the format and
Coding Tools organization of different coding
tools
Healthcare Data Security
and Privacy Understanding HIPAA and its
Medical terminology importance in Healthcare Coding
and Claims Processing
Anatomy and Physiology
1.2 Evaluate Information/Data set Identifying and gathering Lecture Written exam 24
medical necessary in Coding necessary information or Data Discussion Demonstration
reports sets in Coding Demonstration Interview
Data management
Coding Guidelines and Identifying and understanding all
Conventions the appropriate Coding
conventions and guidelines.
Current Coding practices
Identifying standard coding
practices
1.3 Assign codes Basic Coding steps Knowing the basic coding steps. Lecture Written exam 80
Discussion Demonstration
Classification of Diagnoses Assigning appropriate diagnoses
Demonstration Interview
Codes codes
Classification of Procedure Assigning appropriate procedure
and Supply codes and supply codes
Best Practices in Coding Applying best practices in coding
activities
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1. The delivery of training shall adhere to the design of the curriculum. Delivery shall be
guided by the principles of competency-based TVET.
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2.2 Enterprise-Based:
The trainees who wish to enter the course should possess the following
requirements:
Graduate of 12-years Basic education;
Can communicate in English, both oral and written;
Have pass the trainability/aptitude test of the institution*
___________
Note: * Optional
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MATERIALS
At least 5 sets Coding Manuals (latest edition or at least 2-years of publication)
Coding Resources Diagnosis code set
Procedures/Services and Supplies code set
Claims Processing Manuals / Handouts
1:1 Training/Student manual (optional)
At least 2 pcs Latest Medical Dictionary
At least 2 sets Computers with internet (optional)
Total 64
Total Area 83
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With at least two (2) years of relevant industry experience as medical coding
and claims specialist or with international certification in medical coding, billing
and/or claims
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4.1.2 The qualification of Medical Coding and Claims Processing NC III may
be attained through:
4.1.3 Accumulation and submission of all COCs acquired for the relevant units
of competency comprising a qualification, an individual shall be issued the
corresponding National Certificate.
4.1.4 Assessment shall focus on the core units of competency. The basic and
common units shall be integrated or assessed concurrently with the core
units.
4.1.5 The following are qualified to apply for assessment and certification:
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4.1.5.3 Those who are included in the national ICD10 Training Registry of
DOH/WHO
4.1.6 The conduct of assessment and issuance of certificates shall follow the
procedures manual and implementing guidelines developed for the
purpose.
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BASIC COMPETENCIES
Receive and Respond Practice basic
Demonstrate work Participate in Workplace
to Workplace Work with Others housekeeping
values Communication
Communication procedures
Practice occupational
Work in a Team Practice career Lead Workplace
health and safety Lead Small Team
Environment professionalism Communication
procedures
Solve Problems Use mathematical
Develop and practice Use relevant Utilize Specialist
Related to Work concepts and
negotiation skills technologies Communication Skills
Activities techniques
Apply Problem Solving
Develop Team and Collect, analyze and Promote environmental
Techniques in the Plan and Organize Work
Individuals organize information protection
Workplace
COMMON COMPETENCIES
Perform Mensuration Prepare and Interpret Apply Quality Perform Computer
Use Hand Tools
and Calculation Technical Drawing Standards Operations
CORE COMPETENCIES
Provide specialized
Communicate
Render quality Utilize enterprise/ Conduct contact center support and
effectively in a customer
customer service company technology campaign assistance to
contact center
customers
Manage the activities of Use medical
Lead a contact center Use business Produce text from
a contact center work technology to carry out
work team technology audio transcription
team task
Lead a team in Produce cleaned-up
Manage the activities Create 2D models
Review/edit documents delivering quality and in-between
of a work team and images
service drawings
Produce key Produce over-all
Produce 2D colored Produce background Composite and edit
drawings for designs for
animation designs animation sequence
animation animation
Coordinate the
Create 3D models and Produce storyboard
production of
images for animation
animation
Process medical Manage medical
Assign medical codes
claims/billings claims
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DEFINITION OF TERMS
GENERAL
3) Common Competencies - are the skills and knowledge needed by all people
working in a particular industry
8) Core Competencies - are the specific skills and knowledge needed in a particular
area of work - industry sector/occupation/job role
10)Elective Competencies - are the additional skills and knowledge required by the
individual or enterprise for work
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20)Basic Competencies - are the skills and knowledge that everyone needs for work
23)Underpinning Skills - refers to the list of the skills needed to achieve the elements
and performance criteria in the unit of competency. It includes generic and
industry specific skills
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SECTOR SPECIFIC
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from the patient's insurance company. The medical claims processor then
reviews and assesses the claim, remitting payment to the doctor if a claim is
covered by the patient's insurance policy. Due to the nature of the work, it is
vital that the processor be knowledgeable about the health insurance industry.
19. Outsourcing – turning over all or part of an organization’s information systems
operation to outside contractors, known as systems integrators or facilities
management companies.
20. Physiology – the branch of biology concerned with the functions of living
things.
21. Protocol – a set of rules and procedures for the control of communication in a
communications network.
22. Quality Assurance – methods for ensuring that information systems are free
from errors and fraud and provide information products of high quality.
23. Software – computer programs and procedures concerned with the operation
of an information system.
24. Standards – measures of performance developed to evaluate the progress of
a system toward its objectives
25. System – an assembly of methods, procedures, or techniques unified by
regulated interaction to form an organized whole
26. User- friendly – a characteristic of human-operated equipment and systems
that makes
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ACKNOWLEDGEMENTS
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