BSBMED301B Interpret and apply medical terminology appropriately Revision Number: 1
BSBMED301B Interpret and apply medical terminology appropriately Modification History Not applicable. Unit Descriptor 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 Approved Page 2 of 11
Employability Skills Information Employability skills This unit contains employability skills. Elements and Performance Criteria Pre-Content Elements describe the essential outcomes of a unit of competency. Performance criteria describe the performance needed to demonstrate achievement of the element. 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. Approved Page 3 of 11
Elements and Performance Criteria ELEMENT 1. Respond appropriately to instructions which contain medical terminology 2. Carry out routine tasks 3. Use appropriate medical terminology in oral and written communication PERFORMANCE CRITERIA 1.1. Receive, interpret and document written and oral instructions using 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 2.1. Use medical terminology correctly in the completion of routine tasks 2.2. Seek assistance from supervisor or experienced staff member as required 3.1. Use appropriate medical terminology as directed, in oral communication with patients, fellow workers 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 Approved Page 4 of 11
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. Approved Page 5 of 11
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 demonstrate competency in this unit Context of and specific resources for assessment Method of assessment Evidence of the following is essential: 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. Assessment must ensure: access to an actual workplace or simulated environment access to office equipment and resources examples of documentation and resources. 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. Approved Page 6 of 11
EVIDENCE GUIDE 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. Approved Page 7 of 11
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: Medical terminology 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 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 Approved Page 8 of 11
RANGE STATEMENT Policies and procedures may include: Clarification may be sought from: medications referrals terms to describe onset and/or nature of disease 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 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 Approved Page 9 of 11
RANGE STATEMENT Oral communication may include: Written communication may include: Designated person may include: doctor practice manager supervisor 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 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 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 Unit Sector(s) Approved Page 10 of 11
Unit sector Competency field Competency field Administration - Medical Services Administration Co-requisite units Co-requisite units Approved Page 11 of 11