medical terminology appropriately

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BSBMED301B
Interpret and apply medical
terminology appropriately
Learner Guide
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Table of Contents
Table of Contents……………………………………………………………………………………………………………… 1
Unit of Competency …………………………………………………………………………………………………………….. 3
Performance Criteria……………………………………………………………………………………………………………. 4
Foundation Skills …………………………………………………………………………………………………………………. 5
Assessment Requirements……………………………………………………………………………………………………. 6
Housekeeping Items ……………………………………………………………………………………………………………….. 7
Objectives ……………………………………………………………………………………………………………………………… 7
1. Respond appropriately to instructions which contain medical terminology………………………………. 8
1.1 – Receive, interpret and document written and oral instructions using medical terminology……… 9
Written and oral instructions………………………………………………………………………………………………… 9
Medical terminology……………………………………………………………………………………………………………. 9
Anatomy and physiology…………………………………………………………………………………………………….. 13
Cardiovascular system ……………………………………………………………………………………………………….. 13
Respiratory system…………………………………………………………………………………………………………….. 17
Musculoskeletal system……………………………………………………………………………………………………… 20
Endocrine system………………………………………………………………………………………………………………. 25
Nervous system…………………………………………………………………………………………………………………. 28
Digestive system ……………………………………………………………………………………………………………….. 30
Urinary system ………………………………………………………………………………………………………………….. 31
Reproductive system………………………………………………………………………………………………………….. 33
Integumentary system ……………………………………………………………………………………………………….. 36
Lymphatic system ……………………………………………………………………………………………………………… 37
Activity 1A ………………………………………………………………………………………………………………………… 39
1.2 – Use checklists where appropriate……………………………………………………………………………………. 40
Using checklists …………………………………………………………………………………………………………………. 40
Activity 1B ………………………………………………………………………………………………………………………… 41
1.3 – Interpret abbreviations for specialised medical terminology………………………………………………. 42
Common abbreviations and acronyms …………………………………………………………………………………. 42
Activity 1C ………………………………………………………………………………………………………………………… 44
1.4 – Interpret and adhere to the policies and procedures of the workplace ……………………………….. 45
1.5 – Seek clarification when necessary …………………………………………………………………………………… 45
Ensure own understanding of policies and procedures ………………………………………………………….. 45
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Policy examples…………………………………………………………………………………………………………………. 45
Seeking clarification …………………………………………………………………………………………………………… 48
Activity 1D ………………………………………………………………………………………………………………………… 50
2. Carry out routine tasks …………………………………………………………………………………………………. 51
2.1 – Use medical terminology correctly in the completion of routine tasks ………………………………… 52
Routine tasks…………………………………………………………………………………………………………………….. 52
Activity 2A ………………………………………………………………………………………………………………………… 54
2.2 – Seek assistance from supervisor or experienced staff member as required………………………….. 55
Seeking assistance from supervisor ……………………………………………………………………………………… 55
Ethical dilemmas ……………………………………………………………………………………………………………….. 55
Activity 2B ………………………………………………………………………………………………………………………… 57
3. Use appropriate medical terminology in oral and written communication ……………………………… 58
3.1 – Use appropriate medical terminology as directed, in oral communication with patients, fellow
workers and health professionals……………………………………………………………………………………………. 59
Oral communication ………………………………………………………………………………………………………….. 59
Teamwork and multi-disciplinary teams……………………………………………………………………………….. 59
Activity 3A ………………………………………………………………………………………………………………………… 61
3.2 – Use appropriate medical terminology as directed, in written communication with patients,
fellow workers and health professionals………………………………………………………………………………….. 62
3.3 – Present written communication to a designated person for verification if required………………. 62
Written communication……………………………………………………………………………………………………… 62
Verification……………………………………………………………………………………………………………………….. 63
Freedom of information……………………………………………………………………………………………………… 63
Activity 3B ………………………………………………………………………………………………………………………… 64
3.4 – Spell and pronounce medical terminology correctly………………………………………………………….. 65
Spelling and pronouncing medical terminology correctly ……………………………………………………….. 65
Pronunciation……………………………………………………………………………………………………………………. 65
Spelling…………………………………………………………………………………………………………………………….. 66
Activity 3C ………………………………………………………………………………………………………………………… 68
Activity 4 – Skills and Knowledge Activity………………………………………………………………………………. 69
Activity 5 – Major Activity…………………………………………………………………………………………………… 70
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Unit of Competency
Application
This unit describes the 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; as well as use appropriate medical terminology.
It applies to individuals who 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.
No licensing, legislative or certification requirements apply to this unit at the time of publication.
Unit Sector
Administration – Medical Services Administration
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Performance Criteria
Element
Elements describe the
essential outcomes.
Performance Criteria
Performance criteria describe the performance needed to
demonstrate achievement of the element.
1. Respond appropriately
to instructions which
contain medical
terminology
1.1 Receive, interpret and document written and oral
instructions using medical terminology
1.2 Use checklists where appropriate
1.3 Interpret abbreviations for specialised medical terminology
1.4 Interpret and adhere to the policies and procedures of the
workplace
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 and written
communication
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
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Foundation Skills
This section describes language, literacy, numeracy and employment skills incorporated in the
performance criteria that are required for competent performance.
Skill
Performance Criteria
Description
Reading
1.1-1.4, 3.2, 3.4
 Interprets technical language within various texts
 Determines how content can be used appropriately in the
workplace
Writing
1.1, 1.2, 1.5, 2.1, 3.2,
3.3, 3.4
 Uses clear, specific and industry related terminology to
complete and update workplace documentation
Oral
Communication
1.5, 2.1, 2.2, 3.1, 3.2,
3.4
 Pronounces complex and specific words correctly and uses
them in the correct context
 Seeks the view and opinions of others by listening and
questioning
Navigate the
world of work
1.4
 Understands and operates within organisational
procedures and policies
Interact with
others
1.1, 1.5, 2.2, 3.1-3.3
 Selects the appropriate form, channel and mode of
communication for a specific purpose relevant to own role
Get the work
done
1.1, 1.2
 Plans a range of routine tasks, accepting goals and aiming
to achieve them efficiently
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Assessment Requirements
Performance Evidence
Evidence of the ability to:
 Interpret and follow written instructions containing medical terminology
 Produce documents containing correct medical terminology according to organisational
requirements
 Use medical terminology correctly in oral communications
 Identify and use appropriate abbreviations for medical terms and associated processes.
Note: if a specific volume or frequency is not stated, then evidence must be provided at least once.
Knowledge Evidence
To complete the unit requirements safely and effectively, the individual must:
 Outline medical terminology relevant to the practice, including the fundamental word structure
used in medical terms
 Outline the relevant policies and procedures
 Identify sources of information available to check on medical terminology.
Assessment Conditions
Assessment must be conducted in a safe environment where evidence gathered demonstrates
consistent performance of typical activities experienced in the medical services administration field of
work and include access to:
 Office equipment and resources
 Examples of documentation
 Case studies and, where possible, real situations.
Assessors must satisfy NVR/AQTF assessor requirements.
Links
Companion volumes available from the IBSA website: http://www.ibsa.org.au/companion_volumes
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Housekeeping Items
Your trainer will inform you of the following:
 Where the toilets and fire exits are located, what the emergency procedures are and
where the breakout and refreshment areas are.
 Any rules, for example asking that all mobile phones are set to silent and of any
security issues they need to be aware of.
 What times the breaks will be held and what the smoking policy is.
 That this is an interactive course and you should ask questions.
 That to get the most out of this workshop, we must all work together, listen to each
other, explore new ideas, and make mistakes. After all, that’s how we learn.
 Ground rules for participation:
o Smile
o Support and encourage other participants
o When someone is contributing everyone else is quiet
o Be patient with others who may not be grasping the ideas
o Be on time
o Focus discussion on the topic
o Speak to the trainer if you have any concerns
Objectives
 Discover how to respond appropriately to instructions which contain medical
terminology
 Know how to carry out routine tasks
 Learn how to use appropriate medical terminology in oral and written communication
 Gain skills and knowledge required for this unit
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1. Respond appropriately to instructions which contain
medical terminology
1.1. Receive, interpret and document written and oral instructions using medical terminology
1.2. Use checklists where appropriate
1.3. Interpret abbreviations for specialised medical terminology
1.4. Interpret and adhere to the policies and procedures of the workplace
1.5. Seek clarification when necessary
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1.1 – Receive, interpret and document written and oral instructions using
medical terminology
Written and oral instructions
When working in a medical administrative environment, you will receive both written and oral
instructions that you will have to interpret and document.
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.
Health professionals, clients or family members may need or want to know information about a client’s
health, appointments, progress, medication etc. You may receive this information verbally; over the
telephone or face to face, or via written documentation; either electronic or hardcopy.
You will need to judge where the information you receive needs to be documented – for example, in a
patient’s notes, in the diary, care plan etc. You will also need to predict who might need such
information and inform them at your nearest opportunity.
You may need to pass information over to family or health professionals. If passing information from
health professionals to others, you may need to interpret and correctly document medical terminology
that they have used, so that you can communicate this clearly to a third party (either orally or written).
Medical terminology
Using appropriate terminology is about being able to effectively describe the treatment and related
problems. Documentation needs to be clear and precise in its description and the use of appropriate
terminology can help with this. Terminology may also be used to minimise the event of a mistake or
failure to understand.
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Some basic health terminology can be found below. This is not an extensive list but gives you an idea as
to the type of terminology used in the healthcare service.
Medical terminology may include:
 Abbreviations for medical and pharmacological terms, for example;
o BCG – Bacille Calmette Guerin (the vaccine against tuberculosis)
o HRT – Hormone replacement therapy
o IVP – Intravenous Pyelogram (the use of die to show anatomy of kidneys and the
urinary tract)
o TAB – A vaccine for typhoid
o ANTE – means before e.g. antenatal – before birth
o UNG – short for unguentum (meaning ointment)
 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). Other systems
include:
o Cardiovascular system
o Respiratory system
o Endocrine system
o Digestive system
o Urinary system
o Reproductive system
o Integumentary system
o Lymphatic system.
 Common medical conditions including illnesses, injuries and diseases;
o Diabetes
o Heart disease
o Postnatal depression
o Osteoporosis
o Osteoarthritis
o Sprains, fractures, breaks
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o Menopause
o Parkinson’s disease
o Alzheimer’s disease
o Dementia
o Cataracts
o Glaucoma
o Renal disease
o Shingles.
 Departments/sections in a hospital, for example;
o Accident and Emergency
o Anaesthetics
o Cardiology
o Diagnostic imaging
o Ear, nose and throat department
o Elderly service
o Gastroenterology
o General surgery
o Gynaecology
o Maternity
o Microbiology
o Neonatal
o Neurology
o Nutrition
o Oncology
o Orthopaedics
o Pharmacy
o Physiotherapy
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o Radiotherapy
o Urology.
 Health insurance terminology, for example;
o Actuary: someone who is trained in statistics and mathematical elements of
insurance.
o Ancillary products: extra insurance products that may be added to medical
insurance at an additional cost.
 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, for example:
o Paediatrician – children’s specialist
o Geriatrician – Elderly specialist
o Anaesthetist – part of surgical team – gives local, regional and general
anaesthetic.
o Ophthalmologist – specialises in eyes and vision.
 Medical conditions
 Medical equipment and instruments:
o Thermometer
o Fob watch
o Stethoscope
o Enteral feeding tubes
o Oxygen tanks and masks
o CPAP machine
o Stats machines for reading oxygen levels and blood pressure.
 Medical investigations and procedures, for example;
o Blood transfusion
o Appendectomy
o Biopsy.
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 Medicare terminology
 Medications, for example;
o Antibiotics to treat infections
o Inhaler
o Oxygen therapy
o Vaccinations
o Pain relievers e.g. Paracetamol, Co-codamol, Morphine
o Antidepressant e.g. selective serotonin reuptake inhibitors (SSRI’s) such as,
Fluoxetine, serotonin-noradrenaline reuptake inhibitors (SNRI’s) such as,
duloxetine.
 Referrals e.g. from General Practitioners
 Terms to describe onset and/or nature of disease, for example:
o Chronic – Issues are ongoing and permanent or long term
o Acute Issues – severe but short term issues
o Early onset – refers to someone being diagnosed with a disease that usually does
not affect people under a certain age, e.g. under 65’s are not usually diagnosed
with Alzheimer’s disease.
There are many terms that you will need to become familiar with and use when writing communications
and plans to support healthcare practices. The above are select examples and you will need extra
research and time to become familiar with relevant terms in your work area. Your supervisor may be
able to help you with appropriate terms and it is also a good idea to keep a glossary book so that you
can note terms down when you come across them.
Anatomy and physiology
When working with people in a medical or care context, it is essential to have a good basic knowledge of
the body’s systems – this will help you understand conditions, recognise concerning symptoms more
easily and be able to document them using appropriate terminology.
Cardiovascular system
This system consists of the heart, blood vessels and around five litres of blood that it transports around
the body. It is responsible for transporting oxygen, hormones, nutrients and waste products around the
body. The heart powers this system, pumping the blood which carries the previously mentioned
contents at a rate of five litres per minute.
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The heart
This is a muscle that is located in the thoracic region, between the lungs. Two thirds of the heart is on
the left side of the body; the top of the heart is connected to the aorta, vena cava, pulmonary trunk and
pulmonary veins – the major blood vessels. It is a four chambered ‘double pump’ where the left and
right sides function separately – the right side pumps deoxygenated blood and the left side oxygenated
blood. Each heartbeat pumps both sides of the heart simultaneously.
Circulatory loops
In the human body, there are two circulatory loops:
 Pulmonary circulation loop – transports deoxygenated blood from the right side of the
heart to the lungs; here, the blood becomes re-oxygenated and is transported back to
the left side of the heart. The right atrium and right ventricle pump blood along this
loop.
 Systemic circulation loop – transports oxygenated blood from the left side of the heart
to all body tissue (apart from the heart and lungs). It also removes waste from tissue
and returns deoxygenated blood to the right side of the heart. The left atrium and left
ventricle pump blood along this loop.
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Blood vessels
These allow blood to travel from the heart to every area of body and back – they are sized according to
how much blood passes through that particular area of the body. Blood travels through a hollow area
called the lumen, which is encased in a wall (thin for capillaries and thick for arteries). The blood vessels
are lined with endothelium which keeps blood inside them and prevents the formation of clots.
There are three types of blood vessels:
 Arteries – they carry blood away from the heart, which is usually oxygenated; the only
exception is the pulmonary trunk circulation loop, which carries deoxygenated blood
from the heart to the lungs. They have high levels of blood pressure, as the blood is
being pushed from the heart (hence the thicker vessel walls). Bigger arteries are more
elastic, to accommodate the pressure, whereas smaller arteries are muscular and
contract/expand to regulate blood flow.
 Arterioles are narrow arteries that branch off from the ends of arteries and carry blood
to capillaries. They have lower blood pressure as they are greater in number, further
from the heart and carry less blood per unit – therefore, the walls are much thinner
than arteries. They also use muscle to regulate blood flow.
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 Capillaries – these are the smallest, thinnest and most common blood vessels in the
body. They run through just about every tissue in the body and connect arteries to
venules. In capillaries, gases, nutrients and waste products are exchanged between
tissues – therefore, the endothelium is thin to allow easier passage of materials, while
still retaining blood cells inside the vessels.
 Precapilliary sphincters regulate blood flow into capillaries by reducing blood flow to
inactive tissue and directing it towards active tissue.
 Veins – they return blood to the heart; their walls are much thinner, less elastic and
less muscular than arteries (as they are not subjected to as much pressure). Instead,
gravity, inertia and skeletal muscle contractions allow veins to push blood back to the
heart. Many veins contain valves that prevent blood from going away from the heart.
Venules perform the same function as arterioles but collect blood from capillaries, rather than deposit
it.
Functions of the cardiovascular system
 Transportation of blood (along with its contents) to body tissue
 Protection – white blood cells clean up debris and fight infections; platelets and red
blood cells form scabs that prevent infection and open wounds; blood also carries
antibodies to help protect from specific infections
 Regulation – helps maintain body temperature; helps balance the body’s pH; maintains
concentration of body’s cells.
Regulation of blood pressure
 The greater the contractions of the heart, the higher the blood pressure
 Vasoconstriction – the diameter of an artery is reduced by contracting the muscle in
the arterial wall. Blood pressure is increased and flow reduced.
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 Vasodilation – the diameter of an artery is increased as the muscle in the arterial wall
relaxes. This can be caused by hormones or chemicals, artificial or natural.
 An increase in blood volumes equals higher blood pressure
 Thicker blood (from clots etc.) raises blood pressure.
Haemostasis
This is where blood clots and forms scabs – it is controlled by the platelets of the blood. Platelets remain
inactive until they reach damaged tissue and they change form to a spiky shape and become sticky in
order to hang on to damaged tissue. They then release chemicals to produce fibrin, which forms the
structure for a blood clot. They will stick together to plug a wound until it can be fully repaired,
protecting it from foreign bodies in the meantime.
Respiratory system
This system provides oxygen to the cells of the body and removes carbon dioxide from them.
It consists of three major areas:
 The airway – nose, mouth, pharynx, larynx, trachea, bronchi, and bronchioles
 The lungs – pass oxygen into the body and carbon dioxide out of it
 Respiration muscles – diaphragm, intercostal muscles.
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Nose/nasal cavity
This nasal cavity is the primary tract through which air moves; the nose is made of cartilage, bone,
muscle and skin, and protects the nasal cavity. The nasal cavity warms, moisturises and filters air that
enters the body before it goes to the lungs. Hairs and mucus trap dust and other contaminants. Exhaled
air returns moisture and heat to the nasal cavity before exiting the body.
Mouth
This is the secondary tract through which breathing takes place and is used when extra air is needed.
However, it doesn’t warm and moisturise air as well as the nose and doesn’t filter as well. However, it
allows more air to enter the body quicker.
Pharynx
This is the throat and is a muscular funnel that goes from the end of the nasal cavity to the oesophagus
and larynx. It contains the epiglottis, which is a flap of cartilage that moves between the trachea and
oesophagus, blocking the correct passage, depending if you are eating or not – this prevents choking.
Larynx
This is the voice box and contains vocal cords, the epiglottis and is constructed of cartilage.
Trachea
This is the windpipe and is made of cartilage rings – it connects the larynx to the bronchi and allows
passage of air into the lungs – it contains mucus to trap external bodies from reaching the lungs. This
mucus is then moved toward the pharynx, where it is swallowed and digested.
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Bronchi/bronchioles
This is where the airway splits into two branches, which then spilt into secondary branches (two in the
left lung, three in the right lung). Secondary bronchi then spilt into tertiary bronchi and then into
bronchioles, which further split until they become less than a millimetre in diameter – these are known
as terminal bronchioles and transfer air into the alveoli of the lungs.
Muscle tissue in the bronchi and bronchioles helps regulate airflow – they relax when more air is
required (e.g. during exercise) and contract when resting to prevent hyperventilation.
Lungs
The lungs are organs and are surrounded by a pleural membrane to allow expansion and a negative
pressure space to allow for passive filling of the lungs as they relax. The left lung is slightly smaller, to
accommodate the heart and only has two lobes, comparative to the right lung’s three.
They contain around 30 million alveoli, which are tiny cup-shaped structures that allow the exchange of
gases between the air in the lungs and the blood passing through the capillaries.
Muscles of respiration
There are muscles surrounding the lungs that allow air to be inhaled and exhaled from the lungs. The
primary muscle responsible for this is the diaphragm – situated at the floor of the thorax. When it
contracts, it moves into the abdominal cavity and allows air to be pulled into the lungs; relaxation of the
muscle allows air to flow back out of the lungs. Intercostal muscles between the ribs assist the
diaphragm in expanding and compressing the lungs.
Types of respiration
There are two types of respiration:
 External respiration – the exchange of gases from the air into the blood
 Internal respiration – the exchange of gases between blood and the tissues of the body.
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Homeostatic control of respiration
When the body is resting, it maintains what is called eupnoea – this is a steady breathing rate and
happens during rest. When we become active, the body requires more oxygen and is producing more
carbon dioxide – therefore, chemoreceptors send signals to the brain which will instruct the body
increase its rate and depth of breathing to cope with the situation.
Musculoskeletal system
This is the structure of the body and consists of the bones, muscles, joints and the tendons and
ligaments that hold them all together.
The function of it is to:
 Protect and support the organs of the body and its internal structures
 Allow movement
 Give shape and structure to the body
 Produce blood cells
 Store calcium and phosphorus
 Produce heat.
The skeletal system
There are 206 bones in the human body – the skeletal system of bones and joints as the supporting
structure of the body.
Bones are made from calcium-phosphorus, organic matter and water. They are covered in periosteum, a
living membrane that houses osteoblasts, which contain bone forming cells. The centre of bone
contains marrow, which consists of fat cells, blood vessels and blood cell manufacturing tissue.
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Bones can be in one of four shapes:
 Flat e.g. ribs
 Irregular e.g. vertebrae
 Short e.g. carpals
 Long e.g. humerus.
Joints allow movement and are where two or more bones are held together by ligaments.
There are three types:
 Fibrous (immovable) e.g. skull
 Cartilaginous (slightly moveable) e.g. vertebrae
 Synovial (freely moveable):
o Ball and socket e.g. hip
o Hinge e.g. knee
o Gliding e.g. wrist (carpals)
o Pivot e.g. radius, ulna
There are various types of movement that the bones of these joints can perform:
 Abduction – away from the body
 Adduction – towards the body
 Flexion – bending a limb towards the body
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 Extension – extension of a limb away from the body
 Rotation – movement around a point.
The muscular system
Muscles provide the contractions and relaxations that move the bones around the joints, working in
conjunction with the skeletal system. There are over 500 muscles in the body; they also help maintain
the position of the body.
Tendons attach muscle to bone; there are three types of muscles:
 Skeletal – also known as voluntary, these attach muscles to bones
 Smooth – also known as involuntary, they control internal processes such as the action
of the gut and blood vessels
 Cardiac – in the heart.
The contraction of a muscle shortens it – this is caused by the release of chemicals by the brain and the
trigger of a motor nerve. The contraction pulls the bone with it; as this happens, the antagonist muscle
relaxes to facilitate the movement – these are known as antagonistic pairs.
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The following two diagrams detail all the major bones and muscles in the body:
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Endocrine system
This system consists of all the glands in the body and the hormones they produce. The glands are
controlled by the nervous system and chemical receptors in the blood. They help maintain homeostasis
(stable internal condition) by regulation of organ functions. Hormones are responsible for things like
metabolism, sexual development and reproductions, mineral and sugar retention, heart rate and
digestion.
Hypothalamus
This part of the brain directly controls the endocrine system through the pituitary gland; it is also
responsible for various nervous system-related jobs. It contains neurosecretory cells – these are
neurons that secrete releasing and inhibiting hormones. These hormones are responsible for the
controlled release of things like growth hormone and follicle stimulating hormone.
Pituitary gland
This is a pea sized piece of tissue connected to the hypothalamus, which releases hormones through
blood vessels surrounding it.
It is made of two parts:
 Posterior pituitary – releases oxytocin (for childbirth contractions and release of milk
for breastfeeding) and antidiuretic hormone (prevents water loss in body by reducing
blood flow to sweat glands and increasing water uptake in kidneys)
 Anterior pituitary – controlled by the hypothalamus, it produces six vital hormones:
o Thyroid stimulating hormone (TSH)
o Adrenocorticotropic hormone (ACTH)
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o Follicle stimulating hormone (FSH)
o Luteinising hormone (LH)
o Human growth hormone (HGH)
o Prolactin (PRL).
Pineal gland
This produces melatonin, to help regulate the sleep-wake cycle – increased production causes feelings
of drowsiness.
Thyroid gland
Located at the base of the neck around the lateral sides of the trachea, it produces:
 Calcitonin – regulating blood calcium levels
 Triiodothyroxine and thyroxine – regulating metabolic rate.
Parathyroid glands
They produce parathyroid hormone (PTH) when calcium ion level drop too low – this stimulates the
osteoclasts to break down the calcium stores from bones, so they are released into the bloodstream. It
also triggers kidneys to return calcium back into the bloodstream.
Adrenal glands
Found above the kidneys, they are made of two layers:
 Adrenal cortex
o produces glucocortoicords (breaks down proteins and lipids; reduces
inflammation and triggers immune response)
o mineralocorticoids (help regulate mineral ions concentration in the body)
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o androgens e.g. testosterone (regulate growth and activity of cells)
 Adrenal medulla – produces epinephrine and norepinephrine, helping increase blood
flow to the brain and muscles under stress (known as ‘fight or flight’ reaction). They
increase heart rate, breathing rate and blood pressure, while decreasing blood flow to
organs that are not involved in responding to emergencies.
Pancreas
This is a large gland near the stomach which releases glucagon to raise blood glucose levels and insulin
to lower them after eating.
Gonads
These are the ovaries (in females) and testes (in males), which produces sex hormones – they determine
the respective secondary sex characteristics of adults.
 Testes – releases testosterone (causes growth and increases in strength of the bones
and muscles, particularly during puberty; causes inherited hair loss; triggers sexual
development)
 Ovaries – release oestrogen and progesterone (for ovulation and pregnancy; for sexual
and growth development during puberty)
Thymus
Found behind the sternum, it produces thymosins (to develop t-lymphocytes during foetal and child
development). During puberty, it becomes inactive and is replaced by adipose tissue.
Other hormone producing organs
 Heart – atrial natriuretic peptide (ANP) in response to high blood pressure levels
 Kidneys – erythropoietin (EPO) in response to low levels of oxygen in the blood
 Digestive system – cholecystokinin (CCK), secretin, and gastrin are all produced by the
organs of the gastrointestinal tract
 Adipose – produces the hormone leptin that is involved in the management of appetite
and energy usage by the body
 Placenta – human chorionic gonadotropin (HCG) assists progesterone by signalling the
ovaries to maintain the production of oestrogen and progesterone throughout
pregnancy
 Local hormones – prostaglandins and leukotrienes are produced by every tissue in the
body (except for blood tissue) in response to damage.
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Nervous system
This is akin to the electrical wiring system of the body and is comprised of nerves that go from the brain
to every part of the body.
Neurons send signals through thin fibres which cause chemicals (neurotransmitters) to be released at
junctions known as synapses. These give a command to a cell to behave in a certain way – this whole
process takes about a fraction of a millisecond.
Sensory neurons react to stimuli such as light, sound and touch – they then send feedback to the brain
through the central nervous system, communicating about the surrounding environment. Motor
neurons transmit messages to activate muscles/glands.
Neurons are help in place by glial cells (neuroglia), which also destroy pathogens, remove dead neurons
and ensure the signals sent by the brain reach their intended target.
The brain
This soft organ is located inside and protected by the skull – it is the main control centre of the body and
contains 100 billion neurons. Along with the spinal cord, it is part of the central nervous system – it is
responsible for things like consciousness, memory, decision-making, involuntary and voluntary
contractions.
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The spinal cord
This is a long, thin column of neurons bundled together – it carries information down and around the
body, resulting in conscious movement, as well as reflexes.
Nerves
Nerves are bundles of axons that are information highways – these bundles are known as fascicles and
are wrapped in a protective layer called the perineurium; groups of these fascicles are wrapped
together to form an entire nerve.
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Digestive system
This is made up of the gastrointestinal (GI) tract, liver, pancreas and gallbladder. In the GI tract, tubes
join from the mouth to the anus, so that food and drink which is ingested is digested and leaves the
body as faeces, once all useful nutrients have been extracted for use in the body.
These useful nutrients include:
 Carbohydrates – they can be simple and complex; they are used for energy and make
up 45-65 per cent of the total daily calorie intake.
 Protein – they are broken down into amino acids, which are the building blocks of the
body and are used for growth and repair.
 Fats – these are a rich source of energy and help absorb vitamins in the body. They
make up 20-35 per cent of daily calories; they are broken down into fatty acids and
glycerol. The body also stores excess energy as fat.
 Vitamins – they can be water-soluble and fat-soluble; each vitamin has a different role
in the growth and health of the body. Fat-soluble vitamins are stored in fat, whereas
water soluble vitamins are flushed out in urine.
There are bacteria in the GI tract called gut flora that help the digestion process, along with the nervous
and circulatory systems.
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Food moves through the GI tract via peristalsis (the movement of organ walls), which also allows the
contents to be absorbed.
The organs involved in the digestive system include:
 Mouth – for chewing and breaking down starches
 Oesophagus – for swallowing
 Stomach – for letting food enter and mix it with digestive juices; it breaks down protein
 Small intestine – for peristalsis and breaking down starches, protein and carbohydrates
 Pancreas – to break down starches, fats and protein
 Liver – to break down fats
 Large intestine – to change waste products into faeces and to excrete it from the body
during a bowel movement.
Digestive juices include:
 Saliva – produced by salivary glands. It contains enzymes and moistens food to allow it
to move more easily through the oesophagus
 Stomach enzymes – produced by the glands in the stomach lining, they digest protein
 Pancreas enzymes – these break down carbohydrates, fats and proteins
 Bile – produced by the liver and stored in the gallbladder, it dissolves fat, so it becomes
digestible
 Small intestine enzymes – they combine with pancreatic juice and bile to complete the
digestive process, breaking down proteins and starches to make glucose molecules.
Urinary system
This is the body’s system for removing urine (made up of waste and excess fluid). For urination to occur,
it requires all of the required parts of the urinary tract to work in sequence.
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The parts of the urinary tract include:
 Kidneys – they filter about 240 to 300 pints of blood to make two to four pints of urine
 Ureters – they carry urine from the kidneys to the bladder
 Bladder – it expands as it fills with urine, and the emptying of it is controlled by the
person. A normal bladder can hold around one and a half to two cups of urine; when it
fills to capacity, signals are sent to the brain to tell them to find a toilet. During
urination, the bladder empties through the urethra. The sphincters (internal and
external) control whether urine stays in the bladder or exits through the urethra.
The kidneys function to:
 Prevent the build-up of waste and extra fluid in the body
 Keep electrolyte levels stable
 Make hormones to regulate blood pressure
 Make red blood cells
 Keep bones strong.
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Reproductive system
These are a collection of organs that combine with the purpose of creating new life (making babies). The
reproductive organs include genitalia and internal organs, such as the gonads.
The male reproductive system consists of:
 Testes – encase in the scrotum, they contain sperm, which are the male sex cells. They
also make male sex hormones, for sexual development
 Glands – they create fluids that mix with sperm
 Sperm ducts – the sperm travel through these and are mixed with fluids from the
glands, created semen
 Urethra and the penis – the urethra can either pass out urine or semen of the body,
depending on whether you are urinating or having sexual intercourse.
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The female reproductive system consists of:
 Ovaries – they contain hundreds of unfertilised eggs (ova). A woman has these cells
from birth (compared to the continual production of sperm in men).
 Fallopian tubes – these connect the ovaries to the uterus. Every month, when an ovary
releases an egg, they are transferred through the fallopian tubes to the uterus.
 Uterus – also known as the womb, this muscular organ is where fertilised eggs develop
into babies.
 Cervix – this is a ring of muscle on the lower part of the uterus – it serves to hold the
baby in during pregnancy.
 Vagina – this is a muscular tube the goes from the cervix to the outside of the body on
a woman. This is also the entrance for a man’s penis during sexual intercourse. The
opening of the vagina has a vulva (two folds of skin, called labia). The urethra opens
into the vulva and is the exit for urine; however, it is a separate entity to the vagina.
The menstrual cycle
This 28 day cycle begins with bleeding of the vagina – this is the lining of the uterus that has been lost.
This is known as having a period or menstruation. This continues for around five days. The uterus lining
begins to re-grow and an egg cell begins to mature in an ovary. On day 14, the mature egg cell is
released into the fallopian tube, towards the uterus (known as ovulation). If the egg is not fertilised by a
sperm cell, the lining of the uterus breaks down and the cycle repeats; if it is fertilised, the egg attaches
to the lining of the uterus and the woman becomes pregnant.
Fertilisation
When a man ejaculates into a woman’s vagina during sexual intercourse, the sperm cells travel to the
uterus through the cervix; there, if it meets with an egg, fertilisation happens and an embryo forms
from the fertilised egg. This then develops into a foetus and then a baby.
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Foetus development
The foetus requires protection, nutrients and oxygen to survive – these are all provided by the mother;
it also needs waste products to be removed.
 Protection – this is done by the uterus and amniotic fluid
 Oxygen and nutrients – this is provided by the placenta
 Waste removal – this is also performed by the placenta
The placenta grows in the wall of the uterus and is connected to the baby via an umbilical cord – it lets
substances pass between the blood supplies of the mother and baby via diffusion but never lets the
blood mix together.
Birth
After nine months, the baby is fully developed and ready to be born and the cervix relaxes as the uterus
wall muscles contract to push the baby out of the body.
Puberty
As a child grows into an adult, they go through puberty (between the ages of ten and 15) – where their
reproductive system develops so that they can produce children of their own.
Some of the other changes include:
 Growth of underarm hair
 Growth of pubic hair
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 Body smells become stronger
 Increased rate of bone and muscle growth
 Emotional development.
In males, the following changes happen:
 The voice breaks
 Testes start producing sperm
 Shoulders get wider
 Testes and penis enlarge
 Hair growth on the face and chest.
In females, the following changes happen:
 Development of breasts
 Ovaries start releasing eggs and periods begin
 Hips get wider.
Integumentary system
This system consists of the skin, the largest organ in the body. It protects the internal parts of the body
from damage, prevents dehydration, stores fat and produces hormones and vitamins. By assisting with
body temperature and water regulation in the body, it helps maintain homeostasis. It is also the first
defence measure against bacteria, viruses and other harmful microbes, as well as ultraviolet radiation.
The skin has receptors that detect heat and cold, pain, pressure and touch.
The components of the skin are:
 Hair
 Nails
 Sweat glands
 Oil glands
 Blood vessels
 Lymph vessels
 Nerves
 Muscles.
(See the diagram below)
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The anatomy of the integumentary system consists of:
 The epidermis – this is comprised of squamous cells which create keratin – this is major
component of skin, hair and nails. It is the outermost layer of the skin. It can either be
thick (on the palms of hands and feet) or thin (rest of the body) skin.
 Dermis – this is the thickest layer of the skin (90 per cent) and it supports the
epidermis. It contains special cells that help regulate temperature, fight infection, store
water and supply nutrients and blood to the skin. They also detect sensations and give
skin its strength and flexibility.
It contains blood vessels, lymph vessels, sweat glands, sebaceous glands, hair follicles,
sensory receptors, collagen and elastin.
 Hypodermis – this innermost layer of the skin helps insulate the body and cushions the
internal organs. It is composed of fat and loose connective tissue and connects skin to
underlying tissues through collagen, elastin and reticular fibres from the dermis. It
contains a specialised tissue called adipose that stores excess energy as fat. Blood
vessels, lymph vessels, nerves and hair follicles also extend through this layer of the
skin.
Lymphatic system
This system’s primary function is to transport lymph, which is a clear and colourless fluid that contains
white blood cells (to fight disease). Lymph helps the body get rid of toxins, waste and other unwanted
substances from the body. It also transports fatty acids from the intestines to the circulatory system.
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The lymphatic system consists of:
 Lymph vessels – they carry lymph through the body and they resemble veins in
structure.
 Lymph nodes (600 to 700) – make more white blood cells, to fight infection.
 Lymph – flows upward towards the neck, through the subclavien veins. It is created
from any fluid that doesn’t return to the heart via the veins.
 Tonsils – clusters of lymphatic cells in the pharynx. They are commonly removed after
persistent throat infections.
 Adenoids.
 Spleen – helps protect against infection and is just above the kidney. Humans can live
without this, but are more prone to injury and infection without it.
 Thymus – in the chest, just above the heart; it stores immature lymphocytes and
prepares them to become active T cells.
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Activity 1A
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1.2 – Use checklists where appropriate
Using checklists
Checklists contain a list of criteria for consideration for specific processes. They help to categorise items,
simplifying the concepts contained within them so that they are easier to remember. The list of items
can then be checked to see if anything has been missed. They are used to improve performance and
prevent errors. This is highly important for health professionals, as they are likely to come across
stressful situations where a checklist can be used as a prompt for memory to ensure specific procedures
have been practiced.
There are many reasons why you may need to use a checklist, these include:
 Medical equipment checklist
 Procedure checklist
 Iterative checklist e.g. checking and reviewing blood pressure, pulse
etc.
 Diagnostic checklist e.g. clinical algorithms
 Criteria of Merit checklist (COM checklist) to diagnose brain death
 Continuing care assessments.
You must bear in mind that checklists can be restrictive; it is up to you and your team to think of
situations where they are needed. In some instances, they may be an unnecessary formality that is
getting in the way (this can be the case if the time it takes up too much time). You should be involved in
the regular reviews of any checklists that you use to ensure that they are working efficiently.
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Activity 1B
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1.3 – Interpret abbreviations for specialised medical terminology
Common abbreviations and acronyms
Abbreviations are used to communicate information succinctly when timeframes are limited. Time is
often stretched in this sector and phrases that are commonly used have become abbreviated for
efficiency.
It is important that you are aware of some of the common abbreviations used in your area (note that
these will differ depending on the area that you work in – for example, if you work with babies you may
need to know LBW stands for low birth weight, however this is not important if you work with the
elderly).
Some common abbreviations include:
BMI – Body Mass Index
DVT – Deep Vein Thrombosis
ECG – Electrocardiogram
EHR – Electronic Health Record
EN – Enrolled Nurse
GP – General Practitioner
HAC – Health and Aged Care (department of)
HACC – Home and Community Care
ICG – Infection Control Guidelines
LBW – Low birth weight
MHS – Mental Health Service
MO – Medical Officer
MRI – Magnetic Resonance Imaging
MRN – Magnetic Records Number
NAPD – National Action Plan for Dementia Care
NENA – National Enrolled Nurses Association
NGOs – Non Government Organisations
OT – Occupational Therapy
OTC – Over-the-counter
PHN – Public Health Nurse
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QA – Quality Assurance
RACS – Residential Aged Care Service
RCF – Residential Care Facility
RCS – Residential Classification Scale
RHD – Rheumatic Heart Disease
RM – Received Money
RN – Registered Nurse
SLA – Service Level Agreement
SOP – Service Outcome Payment
URTI – Upper respiratory Tract Infection
UV – Ultra Violet
VMO – Visiting Medical Officer
WHO – World Health Organisation
YTD – Year to Date.
For more information regarding common abbreviations please go to:
http://www.health.gov.au/internet/main/publishing.nsf/Content/Glossary (accessed 09/07/2014).
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Activity 1C
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1.4 – Interpret and adhere to the policies and procedures of the workplace
1.5 – Seek clarification when necessary
Ensure own understanding of policies and procedures
It is your responsibility to ensure that you understand the policies and procedures relating to medical
administration at your workplace.
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.
Policy examples
Cleanliness and hygiene (infection control)
You should ensure that you follow infection control procedures at all
times. Standard precautions are what you need to implement no matter
what the situation.
They include:
 Washing your hands before and after patient contact
 Using PPE e.g. gloves, masks and plastic aprons
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 Safe use and disposal of sharps
 Routine cleaning e.g. of equipment
 Sterilising tools and only using certain tools once
 Appropriate handling of linen
 If you need to sneeze or cough do this away from the person and into a handkerchief
which you can dispose of (if none available into the crease of your arm).
You may be able to go on courses that provide training for certain policies and procedures. These may
be based on legislation, or best practice.
Work health and safety (WHS)
Workplace Health and Safety (WHS) legislation replaced Occupational Health and Safety (OHS)
legislation in 2011.
WHS legislation stipulates that employers must provide their staff with:
 “ Safe premises
 Safe machinery and materials
 Safe systems of work
 Information, instruction, training and
supervision
 A suitable working environment and
facilities.”
www.business.gov.au, accessed 15/12/2014
Employees are also obliged to ensure that they work safely and do not endanger the safety of their
colleagues, clients and others.
How WHS affects your work in health will vary according to your job role and your industry. In order to
work safely and legally in your role you should have been trained to do so by your organisation, as this is
a legal requirement.
Where you identify possible or actual WHS breaches in your planned responses, they will need to be
reviewed and amended to be compliant immediately before they are used again.
Privacy and confidentiality
The Privacy Act comprises of 13 Privacy Principles that legally must be adhered to and also, as
explained by the Office of the Australian Information Commissioner (OAIC) website:
 “Regulates the collection, storage, use, disclosure, security and disposal of individuals’
tax file numbers
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 Permits the handling of health information for health and medical research purposes in
certain circumstances, where researchers are unable to seek individuals’ consent
 Allows the information commissioner to approve and register enforceable app codes
that have been developed by an app code developer, or developed by the information
commissioner directly
 Permits a small business operator, who would otherwise not be subject to the
Australian privacy principles (apps) and any relevant privacy code, to opt-in to being
covered by the apps and any relevant app code
 Allows for privacy regulations to be made.”
Accessed 16/12/14
Further information on the Privacy Act can be found on the Office of the Australian Information
Commissioner (OAIC) website, which is included within the references section at the end of this Learner
Guide.
Privacy Act
http://www.oaic.gov.au/privacy/privacy-act/the-privacy-act
Providing clients with as much privacy as possible will have a significant impact on their happiness and
self-worth, and make time spent in the setting much more agreeable ; having the privacy and
opportunity to do things also encourages and provides levels of independence that clients may not
necessarily expect.
 Knocking before you enter a room and awaiting an invitation inside will show clients
that they have much more autonomy and respect than having them walked in on with
no warning.
 Closing doors or curtains (in case of ward) while treatment is in progress can maintain
privacy and dignity. Signs that treatment is in progress can sometimes be used
effectively.
 A care provider asking permission to go through their wardrobe can grant clients a
degree of autonomy, self-worth and independence, even if they are being dressed.
 Providing clients with a private room where they can take or make phone calls or
discuss personal issues.
The following guidelines serve as a good basis for maintaining client confidentiality:
 Never discuss client information in social circles
 Documented information should only ever relate to service delivery and related factors
 Confidential documents must be stored securely, out of reach of the public and
unauthorised personnel
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 Client information should never be disclosed to neighbours or family
 Client information should never be disclosed to external agencies that are not part of
the client’s service delivery system
 Names and details of clients should not be disclosed in public forums e.g. meetings,
seminars etc.
There are cases where confidentiality can be broken:
 If the person is at serious risk of harm
 Where there is an imminent, serious threat to the public or a specific person
 Where there is a police request for information under the Police Powers and
Responsibilities Act 2000
 For use by healthcare professional (as long as a recognised standard of treatment is
being delivered).
Issues of confidentiality should never be taken lightly – you should discuss them with your supervisor.
Senior staff should always be involved for complex, competing decisions e.g. confidentiality vs. safety.
Anti-discrimination
In Australia, the following anti-discrimination laws apply:
 Age Discrimination Act 2004
 Australian Human Rights Commission Act 1986
 Disability Discrimination Act 1992
 Racial Discrimination Act 1975
 Sex Discrimination Act 1984.
Full details about these Acts can be found at www.humanrights.gov.au
Seeking clarification
At times, you may be faced with uncertainty, for example you may be asked a question that you do not
know the answer to, you may need to check what a term means, or you may need to check what the
procedure is for something. At these times it is wise to seek clarification.
Clarification may be sought from:
 Drug and prescription information sources/databases
 Experienced staff member/s
 Medical dictionary
 Office practice manual
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 Relevant handbook
 Supervisor.
You will need to use your judgement to determine where to seek clarification. A medical dictionary is
probably a good place to look for terminology, but an experienced staff member or supervisor may also
know. If staff are busy, it could be a good idea to look up the term in the medical dictionary – this also
shows initiative. There may be other terms that you come across that you need to clarify, and it may not
be appropriate to seek clarification from staff several times.
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Activity 1D
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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
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2.1 – Use medical terminology correctly in the completion of routine tasks
Routine tasks
Routine tasks are those tasks that occur regularly on a daily basis. When completing these tasks you will
need to use the correct medical terminology. You should become accustomed to this type of medical
terminology over time.
Routine tasks 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.
It is extremely important to use terminology correctly as misleading information could not only be
confusing, but also have negative consequences.
Consequences of using incorrect medical terminology may include:
 Ordering the incorrect supplies may lead to lack of vital equipment
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 Labelling drugs incorrectly could cause patients to receive the wrong medication – this
could lead to complications and health problems.
 Medical staff could receive the wrong information about patients which could cause
delay in diagnosis and the wrong treatment.
 Writing the wrong terminology down in notes and records could lead to the wrong
treatment being given by health professionals.
 Giving the wrong information to clients and their families could cause unnecessary
distress.
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Activity 2A
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2.2 – Seek assistance from supervisor or experienced staff member as required
Seeking assistance from supervisor
There may be times where you will need to seek assistance from a supervisor or experienced staff
member.
 Supervision may be conducted by various means including:
o In person
o Through use of electronic communications media,
such as telephone or video conferencing, where
necessary
 Frequency of supervision will be determined by factors, such
as the task or the maturity of the person being supervised.
Ethical dilemmas
When there is an ethical dilemma, it is because at least two sets of values are involved, with a decision
to make on which set is most important. You may have to decide which the most important point in the
particular situation is.
Of course, the client’s rights should always be a priority – however, how to actually protect these is not
always obvious, as there can be conflicting opinions from family, co-workers and others involved.
Categories of ethical dilemmas
Competing values:
This is when your responsibility for another conflicts with their ability to make independent decisions.
For example, take an alcoholic – they have the right to self-determination (make their own decisions)
but you have a duty to protect human life and intervene.
Multiple client system:
This is when, in addition to the client, there are other parties involved who have opposing views to the
client. You have to decide who you have an obligation to – usually, it is the client but, if the other parties
are advocates, a dilemma arises. For example, imagine a client wants to refuse life support but their
family is insisting that they remain on it.
Value dilemma:
This is where your personal values conflict with the action you need to take in regards to your work role.
This can arise when you have a legal obligation to report something like abuse, but where you
personally get on with the person accused of said abuse.
An example
An example of a time where you need to ask for assistance is if a client refuses treatment. There is a
legal obligation to obtain client consent – that is, that they agree to services you intend to provide for
them.
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Clients have the right to decide on what care is appropriate for them as long as they have the ability to
make that decision e.g. they are not under the influence of alcohol or drugs or they have the cognitive
capacity i.e. not suffering from a mental illness. This is even the case where death or serious injury may
be the consequence of refusal. Clients may not want treatment based on cultural, religious or personal
beliefs.
Informing a supervisor
You will need to inform a supervisor to ensure that everything has been done to help the client make an
informed choice about their care and understands fully the consequences of the refusal.
They may need to consider:
 Confirming the client has capacity to make the decision
 Checking the patient’s understanding and looking for any health
literacy or communication issues
 Exploring the reasons for the decision including:
o A refusal or an inability to sign the form
o Any cultural or religious conflict that the patient may have
 Exploring other healthcare options that might be acceptable to
them.
 Where necessary, provide further explanation of the healthcare and
consequences using different methods and
 Additional supporting material.
If a client who has capacity to make decisions continues to decline or withdraw consent, the following
can be part of subsequent discussions:
 The consequences and risks of the decision, including how it affects their healthcare
choices, prognosis or outcomes
 That they are entitled to a second opinion and how the health practitioner can
facilitate this
 Their decision to decline or withdraw consent for a specific procedure/treatment does
not affect the provision of other appropriate healthcare and access to health services.
http://www.health.qld.gov.au/consent/documents/ic-guide.pdf (accessed 22/04/2015)
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Activity 2B
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3. Use appropriate medical terminology in oral and written
communication
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
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3.1 – Use appropriate medical terminology as directed, in oral communication
with patients, fellow workers and health professionals
Oral communication
Communication skills are crucial when discussing the needs of a client with patients, fellow workers and
health professionals. You will need to be clear when providing information and listen attentively when
other people are talking. Using the correct medical terminology is important when communicating
orally so that you do not mislead and confuse people.
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.
You will have to alter your communication slightly when dealing with different people and situations.
Fellow workers and health professionals will have a much better understanding of medical terminology
than patients or their families. When talking to families it is important to gauge their understanding and
explain the terms that you use.
When communicating orally with fellow workers and health professionals, you should try your best to
use the correct terminology. If you can, check terms before you communicate. Sometimes it can be
more difficult to prepare if the conversation is spontaneous – for example, dealing with difficult
patients/customers or answering queries either face to face or over the telephone. In these situations,
you could explain that you need to check the terminology first, or ask a supervisor or fellow worker for
help with an explanation.
Teamwork and multi-disciplinary teams
Undertaking work in a multi-disciplinary environment involves working alongside people with different
expertise and within different departments. This is the case in the healthcare profession. A greater
cooperation is therefore needed to be able to achieve the required goals. Attempts should be made to
understand other department’s roles and needs.
If you manage to cooperate and work together as to achieve a common goal you can benefit from all
the advantages that a multi-disciplinary environment has to offer.
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 A large yet closely entwined support base means quick communication between
distinct groups
 A wide range of knowledge and skills can offer the opportunity to transfer skills
 Peer review opportunities enable multi-disciplinary teams to improve and excel.
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Activity 3A
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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
Written communication
Medical administration involves a large amount of written communication that needs to be
documented and conveyed to appropriate people.
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.
You should use appropriate medical terminology when writing information down using any of the above
methods. Abbreviations are a good idea if time is tight e.g. in minutes, but you should only abbreviate
as per your organisational requirements, so that your fellow workers can understand what you have
written.
You should also be familiar with the format of the above written communication methods. Your
organisation will have template documents for some written communications that should be used as
part of organisation policies and procedures.
Accuracy and checking information and terminology
Your organisation may have procedures to help you with accuracy, but here are some general tips and
ideas:
 Read through carefully and check all is information correct
 Ask supervisor when unsure
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 Try to learn common abbreviations so that you can interpret documentation efficiently
 Do not rush – if you rush you might miss something could have detrimental
consequences.
Verification
If you are unsure, or simply want to double check terminology you have used in
written communication, you will need to check with a designated person. This
way you can check whether you have got the correct term and the correct
spelling.
Designated persons may include:
 Doctor
 Practice manager
 Supervisor.
Freedom of information
The Freedom of Information Act 1982 gives people to access to government documents such as policy
information, administrative information and service delivery. This means in a healthcare context that
clients have the right to see information relating to them and any other information already described.
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Activity 3B
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3.4 – Spell and pronounce medical terminology correctly
Spelling and pronouncing medical terminology correctly
Medical terminology can sometimes be difficult to spell and pronounce. However it is extremely
important to spell and pronounce medical terminology correctly to avoid misunderstandings that could
have serious consequences.
Try to remember some words:
 Sound the same but are spelled differently e.g. ileum (part of the intestine) and ilium
(part of the hip bone)
 Sound similar but do not mean the same thing (and are spelled differently) e.g. aphagia
(inability to swallow) and aphasia (inability to speak).
 Can have silent letters (the spelling will not be how it sounds);
o silent p e.g. words beginning with pt , ps e.g. psychology
o ph has an ‘f’ sound e.g. diaphragm (‘g’ sound is also silent here)
 Have more than one way to correctly spell e.g. orthopaedic and orthopedic.
Pronunciation
The table below is a good starting point for learning the pronunciation of medical terms.
Consonant
Example
c before a, o and u = k
coroner, catheter, cure
c before e and i = s
celiac, cirrhosis
ch = k
cholera, cholesterol
g before e and i = j
genetic
ph = f
phobia, physiotherapy
pn = n
pneumonia
ps = s
psychology, psychosis
pt = t
ptosis
rh, rrh = r
rheumatic fever, rhinitis
x (at beginning of word) =z
xerosis
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Spelling
To help you to become familiar with the spelling of medical terms, it can be a good idea to think about
common prefixes and suffixes that are used.
Common prefixes
Prefix
Meaning
a-, an-
without
anti-, contra-
against
de-
from, down or not
ab-
away from
ad-
towards
adip-, adipo-
fat
angi-, angio-
vessel
aur-, auri-, auro-
ear
chrom-, chromate-, chromo-
colour
cyst-, cysti-, cysto-
bladder, cyst, cystic duct
de-
away from
ect-
outer, on the outside
ex-
out of, away from
gyn-, gyne-, gyneco-, gyno-
woman
hem-, hema-, hemat-, hemato-
blood
hyper-
excessive, above normal
hypo-
beneath, the lowest, deficiency
mon-, mono-
single
phleb-, phlebo-
vein
post-
after, behind
pre-
before, anterior
vas-, vasculo, vaso-
duct, blood vessel
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Common suffixes
Suffix
Meaning
-ad, -ar, -ary
pertaining to
-crime
secretion
-cidal, -cide
killing, destroying
-cyte
cell
-dynia
pain
-ectomy
excision
-gram
a recording
-graph
recording instrument
-ia, -iasis
a condition or state
-itis
inflammation
-opia, -opsia
vision
-pathy
disease
-phobia
fear
-ptosis
sagging, falling
-pnea
breath, respiration
-rrhagia
discharge
-rrhea
flow
-scopy
viewing
-stasis
stopping
-trophic, -tropho, -trophy
food, nutrition
-uria
urine, urination
These are just a selection, there are many more – you will need to research and revise the other
prefixes and suffixes. You may be provided with a handbook with them in, but if not, you should write
them down and keep a copy with you at work for reference.
Once you are familiar with common prefixes and suffixes you will be much better equipped to tackle the
spellings and pronunciations of medical terms.
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Activity 3C
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Activity 4 – Skills and Knowledge Activity
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Activity 5 – Major Activity
At the end of your Learner Workbook, you will find an activity titled ‘Major Activity’. This is an
opportunity to revise the entire unit and allows your trainer to check your knowledge and
understanding of what you have covered. It should take between and 1-2 hours to complete and your
trainer will let you know whether they wish for you to complete it in your own time or during the
sessions. Once this is completed, you will have finished this unit and be ready to move onto the next,
well done!
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Congratulations!
You have now finished the unit ‘Interpret and apply medical terminology appropriately.’

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