Unit Descriptor- Medical Terminology
Unit descriptor
This unit describes the performance outcomes, skills and knowledge required to understand and respond
to instructions; to carry out routine tasks and communicate with a range of internal/external clients in a
medical environment; and to use appropriate advanced medical terminology.
No licensing, legislative, regulatory or certification requirements apply to this unit at the time of
endorsement.
Application of the Unit
Application of the unit
This unit applies to individuals who are skilled operators and apply a broad range of competencies in
various medical administration contexts. They may exercise discretion and judgment using appropriate
knowledge to provide technical advice and support to a team.
Licensing/Regulatory Information
Not applicable.
Pre-Requisites
Prerequisite units
Employability Skills Information
Employability skills
This unit contains employability skills.
Elements and Performance Criteria Pre-Content
Elements describe the essential outcomes of a Performance criteria describe the performance needed to demonstrate achievement of the element.
unit of competency.
Where bold italicised text is used, further information is detailed in the required skills and knowledge
section and the range statement. Assessment of performance is to be consistent with the evidence guide.
Elements and Performance Criteria
ELEMENT
PERFORMANCE CRITERIA
1. Respond appropriately to instructions which 1.1. Receive, interpret and document written and oral instructions using medical terminology
contain medical terminology
1.2. Use checklists where appropriate
1.3. Ensure own understanding of abbreviations for specialised medical terminology and associated
processes
1.4. Ensure own understanding of and adhere to, the policies and procedures of the enterprise
1.5. Seek clarification when necessary
2. Carry out routine tasks
2.1. Use medical terminology correctly in the completion of routine tasks
2.2. Seek assistance from supervisor or experienced staff member as required
3. Use appropriate medical terminology in oral 3.1. Use appropriate medical terminology as directed, in oral communication with patients, fellow workers
and written communication
and health professionals
3.2. Use appropriate medical terminology as directed, in written communication with patients, fellow
workers and health professionals
3.3. Present written communication to a designated person for verification if required
3.4. Spell and pronounce medical terminology correctly
Required Skills and Knowledge
REQUIRED SKILLS AND KNOWLEDGE
This section describes the skills and knowledge required for this unit.
Required skills
literacy skills to interpret policies, signs and instructions and to use correct spelling, grammar and punctuation
learning skills to research and increase own knowledge of medical terminology
communication skills to understand, clarify and explain instructions and procedures.
Required knowledge
medical terminology, including the fundamental word structure used in medical terms
basic systems of the body
organisational documentation and recording requirements
source of information relating to medical terminology
key provisions of relevant legislation from all levels of government that affects business operations, codes of practice and national standards, such as:
anti-discrimination legislation
ethical principles
privacy laws
Freedom of Information Act.
Evidence Guide
EVIDENCE GUIDE
The Evidence Guide provides advice on assessment and must be read in conjunction with the performance criteria, required skills and knowledge, range
statement and the Assessment Guidelines for the Training Package.
Overview of assessment
Critical aspects for assessment and evidence required to
Evidence of the following is essential:
demonstrate competency in this unit
using medical terminology in written and verbal communication
identifying and appropriately using abbreviations for medical terms and associated
processes
managing own learning to maintain knowledge of up-to-date medical terminology
knowledge of relevant legislation from all levels of government that impacts on business
operations, codes of practice and national standards.
Context of and specific resources for assessment
Assessment must ensure:
access to an actual workplace or simulated environment
access to office equipment and resources
examples of documentation and resources.
Method of assessment
A range of assessment methods should be used to assess practical skills and knowledge.
The following examples are appropriate for this unit:
direct questioning combined with review of portfolios of evidence and third party workplace
reports of on-the-job performance by the candidate
review of authenticated documents from the workplace or training environment
analysis of responses to case studies and scenarios
demonstration of techniques
observation of presentations
oral or written questioning
observation of performance in role plays
review of written communication with patients for use of appropriate medical terminology
oral or written questioning to assess knowledge of workplace emergencies, risks and
hazards
assessment of documentation.
Guidance information for assessment
Holistic assessment with other units relevant to the industry sector, workplace and job role
is recommended, for example:
other general administration or medical services administration units.
Range Statement
RANGE STATEMENT
The range statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance.
Bold italicised wording, if used in the performance criteria, is detailed below. Essential operating conditions that may be present with training and
assessment (depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts) may also be
included.
Written and oral instructions may include:
diary entries
drugs orders
instructions for postoperative care
notices
occupational health and safety (OHS) signs and instructions
patient notes
referrals
routine reports
telephone calls
test results
theatre lists
verbal instructions
Medical terminology may include:
abbreviations for medical and pharmacological terms (e.g. BCG, HRT, IVP, tab, ante, ung)
causes to changes in the systems of the body (e.g. changes to the musculo-skeletal
system may include inflammation due to repeated strain on the system)
common medical conditions including illnesses, injuries and diseases
departments/sections in a hospital
health insurance terminology
interrelated functions of the body, locations and diseases (e.g. functions of the skeletal
system, locations of skeletal injuries, skeletal diseases
knowledge of medical specialties and the names and titles of doctors working in specialist
fields
medical conditions
medical equipment and instruments
medical investigations and procedures
Medicare terminology
medications
referrals
terms to describe onset and/or nature of disease
Policies and procedures may include:
abiding by local, state/territory and commonwealth legislation
accessing and updating files
cleanliness and hygiene
correspondence format
emergency procedures
following instructions
information specific to the enterprise
office practice manual
OHS
Royal Australian College of General Practitioners (RACGP) Code of Practice for the
Management of Health Information in General Practice
RACGP Entry Standards for General Practices
telephone protocol
recording information
security, confidentiality and privacy procedures
Clarification may be sought from:
drug and prescription information sources/databases
experienced staff member/s
medical dictionary
office practice manual
relevant handbook
supervisor
Routine tasks may include:
answering patient enquiries
contributing to meetings
dealing with patient complaints
entering patient details into computer system
filing patient notes
maintaining information to assist patients
maintaining patient information
maintaining reception area, waiting room, consultation room
ordering stock (e.g. stationery, medical supplies)
preparing medical equipment
preparing reports
processing correspondence
producing a range of complex medical documents (e.g. patient history, case report)
providing information to patients
receiving and making telephone calls
receiving visitors and patients
recording information
storing and maintaining security of drugs
word processing
Oral communication may include:
answering routine telephone enquiries
communicating with a range of medical/hospital professionals on patient related matters
confirming appointments
dealing with difficult patients/customers
paging staff
reporting to staff at meetings
transferring calls
verbal instructions
Written communication may include:
appointment diaries, cards
case reports
complex correspondence to a range of medical/hospital professionals on patient related
matters
forms
letters
memoranda
minutes
patient histories
patient history questionnaires
patient records
telephone messages
Designated person may include:
doctor
practice manager
supervisor