Knowledge/Skills Assessment

Criteria
Unit code, name and release number
BSBMED301 – Interpret and apply medical terminology appropriately (Release 1)

Qualification/Course code, name and release number

HLT33115 – Certificate III in Health Services Assistance (2)

HLT37315 – Certificate III in Health Administration (2)

HLT43015 – Certificate IV in Allied Health Assistance (2)

HLT47315 – Certificate IV in Health Administration (2)

HLT57715 – Diploma of Practice Management (1)

Student details
Student number
880835756

Student name
Terrence Siupan

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 Version: 20190521

For queries, please contact:

Health, Wellbeing and Community Services SkillsPoint
Cnr MacQuoid Street & Buttle Street
QUEANBEYAN NSW 2620

© 2019 TAFE NSW, Sydney

RTO Provider Number 90003 | CRICOS Provider Code: 00591E
This assessment can be found in the: Learning Bank
The contents in this document is copyright © TAFE NSW 2019, and should not be reproduced without the
permission of the TAFE NSW. Information contained in this document is correct at time of printing: 8 July 2021.
For current information please refer to our website or your teacher as appropriate.

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 Assessment Instructions
Table 1 Assessment instructions

Assessment details Instructions

Assessment overview The objective of this assessment is to assess your knowledge and
performance as would be required to interpret and apply medical
terminology.

Assessment Event 1 of 3
number

Instructions for this This assessment is a combination of knowledge questions and case
assessment studies. It will be assessing you on your knowledge and performance
of skills required by the unit.
This assessment is in 7 parts:
1. Policies and Procedures (Short Answer Questions)
2. Abbreviations Assessment (Short Answer Questions)
3. Basic word structure
4. Body Systems
5. Written communication – Short Answer Questions

Submission On completion of this assessment, you are required to upload it or

instructions hand it to your Teacher for marking.
Ensure you have written your name at the bottom of each page of
this assessment.
It is important that you keep a copy of all electronic and hardcopy
assessments submitted to TAFE and complete the assessment
declaration when submitting the assessment.

What do I need to do To achieve a satisfactory result for this assessment all questions must
to achieve a be answered correctly.
satisfactory result?

What do I need to Pens or suitable electronic device.

provide?
If this assessment is being used for online/distance delivery, the
student must upload the assessment.

What the assessor will Access to resource available online & assessment audio-recording.
provide?

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 Due date and time As per the training plan
allowed

Assessment feedback, Appeals are addressed in accordance with Every Students Guide to
review or appeals Assessment.

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 Part 1: Policies and Procedures – Short Answer Questions
1. What is the difference between a Policy and a Procedure?
(Please provide a short answer response to this question – 50 words or less)
Policy is a set of rules or guidelines while procedure is the step-by-step instructions for a
task.

2. Why is it necessary to understand and adhere to facilities policies and procedures

that involve the use of Medical Terminology? You may wish to use an example to
highlight your point
(Please provide a short answer response to this question – minimum 50 words)

As a health care worker, it is important to understand the facility’s policies and

procedures as well as knowing the use of medical terminologies. Policy and procedure
consist of different topics from emergency and security procedures to telephone
protocol and correspondence format, therefore understanding this would assist staff in
knowing how to perform a certain task. It also informs the staff what is expected from
them in the workplace.

3. List 3 ways that a healthcare facility’s policies and procedures regarding Medical
Terminology can be communicated to staff:
(Please provide a short answer response to this question – 50 words or less)

1. Taking a message

2. Passing on a message

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 3. Making an appointment

4. List 3 Legislative Acts that regulate the use of Medical Terminology:

(Please list each Act – no minimum word count required)

1. Work Health and Safety Act 2012 (WHS Act)

2. Health Records and Information Privacy Act 2002 (NSW)

3. Government Information (Public Access) Act (GIPA) 2009

{You can refer to your online resources for further information}

4. Describe the correct action that a healthcare worker should take if they encounter
a medical term that they are unfamiliar with, that they do not know how to spell
or that they cannot pronounce:
(Please provide a short answer response to this question – minimum 50 words)
Being a healthcare worker knowing and understanding medical terminologies is a
must but in case of encountering a medical term that you’re unfamiliar with you
should break down the word so that it would make sense and use the four
fundamental elements of the medical terminology which are the: root word, prefix,
suffix, and the combining form. If having a hard time breaking it down, try to note the
medical term even if you don’t know the spelling or the pronunciation and ask a
colleague or a senior that could teach you the medical terms.

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 6. Prior to releasing documentation that contains medical terminology, healthcare
workers must take what action?
(Please provide a short answer response to this question – minimum 50 words)
Before releasing documents that contains medical terminologies, the documents should
be clear, legible, concise, and accurate so that it is easy to understand, and it could
lessen the possibility of giving out incorrect information. Healthcare workers should also
present the document to the designated clinically qualified person for verification before
it to be released.

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 7. The use of checklists within the healthcare industry ensures consistency across work
practices and aids in the completeness of tasks being undertaken. It also improves
individual accountability for tasks being completed. Within a healthcare facility, individual
patient’s files contain a wealth of information relevant to the ongoing medical
management of the patient and covers a whole range of patient-related information.
Briefly discuss 2 benefits of using a checklist-tool in a healthcare facility for the collection
of all relevant patient-centred information. {You may wish to use an example of what
items would be included on a checklist to ensure all relevant patient data is captured and
stored on their file}
(Please provide a short answer response to this question - 50 words or less)

1. Checklists improve and increase the patient’s safety. It also creates a greater
sense of confidence that the process is completed accurately and thoroughly.

2. Checklists can have a significant positive impact on health outcomes, including

reducing mortality, complications, injuries and other patient harm.

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 Part 2: Abbreviation Assessment Task
Please read the following sentences and provide the correct expanded medical term for
each abbreviation
NOTE: Use the context of the sentence to determine the correct meaning or tense of an
abbreviation
1. The pt was BIBA to the ED with ↓ BP and ↑resp rate:
(Expanded medical term only required)
Pt: Patient

BIBA: Brought in by Ambulance

ED: Emergency Department

↓: Low

BP: Blood Pressure

↑: High

Resp: Respiratory

2. The CIO checked the pt’s DOB, MRN and COB.

(Expanded medical term only required)

CIO: Chief information Officer

DOB: Date of Birth
MRN: Medical Record Number
COB: Country of Birth
3. New admission to ward for R/V by the ENT Reg ASAP

(Expanded medical term only required)

R/V: Review

ENT: Ear, Nose, Throat

Reg: Regular

ASAP: As Soon As Possible

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 4. GP R/F of a 60 y/o M for Tx of # Rt wrist:
(Expanded medical term only required)
GP: General Practitioner

R/F: Reference

M: Male

Tx: Treatment

#: Fractured

Rt: Right

5. He has no Hx of heart ∆, nausea and small amount of Wt loss over last 3/12:
(Expanded medical term only required)
Hx: History

∆: Disease

Wt: Weight

3/12: 3 months

6. Mr Wong has 2 o burns and ++ ketones showing in his urinalysis:

(Expanded medical term only required)
2o burns: Second Degree Burns

++: Moderate

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 7. MO R/V 6/7 ago, given ten-day PO course of antibiotics → +++ diarrhoea:

(Expanded medical term only required)

MO: Medical Officer

R/V: Review

6/7: 6 days

PO: Orally

→: Causes

+++: Excessive

8. Mrs Tanchev has been R/F to Occ Therapy for assessment of ADLs.
(Expanded medical term only required)
R/F: Referred

Occ Therapy: Occupational Therapy

ADLs: Activities of Daily Living

9. You are currently working in a busy healthcare facility and encounter a medical abbreviation
that you do not understand. What should you do?

(Please provide a short answer response to this question – minimum 50 words)

As a healthcare worker in a busy healthcare facility, if I encounter a medical abbreviation

that I don’t understand, asking a senior or a colleague that could help you translate it is a
priority because guessing the abbreviation could result to a wrong diagnosis or wrong
treatment that could be harmful or even fatal for the patient.

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 10. How can healthcare workers develop their understanding of abbreviations and
acronyms? What possible workplace/industry resources could be of use?
(Please provide a short answer response to this question – minimum 50 words)
To improve understanding of medical abbreviations and acronyms they could learn the
Latin root words. Breaking the down the word to its components they easily decipher its
meaning. Focusing on the common Latin or Greek roots, prefix, and suffix would help them
develop their understanding because most medical terms came from Latin or Greek words.
Working every day in a healthcare facility would also help because professionals usually use
medical abbreviations and acronyms. There are also tons of industries that teaches
students on understanding the medical abbreviations and acronyms.

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 Part 3: Basic Word Structure:
1. List and describe the 4 fundamental elements of a Medical term
(No minimum word count)
1.Word Root- It is the fundamental part of the word, it provides the meaning of the word, often
indicates the body part, combines with a suffix to make a word.

2.Prefix- If present it is always at the beginning of a word, it changes or modifies the meaning of
an existing medical term, and it can have more than one meaning.

3.Suffix- It is always at the end of a medical term, it follows a combining form or a prefix, it adds
meaning to the combining form or prefix, and it can have more than one term that means the
same thing.

4.Combining Form- A combination of a word root and a combining vowel, it is often easier to
pronounce than the word root on its own, and it can be written either as gastr/o or gastro.

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 2. Using your Medical Dictionary, identify and define the meaning of the following word elements: (No minimum word count)
Word: Element: (e.g. root, prefix, suffix) Meaning:

gastr Root stomach

hypo Prefix Below, under, less than

physis Suffix Growth

antero Prefix Before, Earlier, Front

osis Suffix Diseased condition or increase, status

ial Suffix Relating to

brady Prefix Slowness

bucc Root Cheek

genic Suffix Produce, Form

pathy Suffix Disease, Suffering

phagia Suffix Ingestion, Eating, Devouring

staxis Suffix Dripping, Flowing

metry Suffix Measuring

pulmon Prefix Lungs

mast Prefix Breast

Sclerosis: Suffix Hardening

Part 4: Body Systems

1. Using the following table, identify the appropriate body system for the following organs: (Please tick the appropriate box)
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 Integumentar Respiratory Nervous Cardiovascular Musculoskeletal Gastrointestinal Reproductive Endocrine Lymphatic
y

trapezius         

epidermis         

thymus         

aorta         

larynx         

spleen         

skin         

bowel         

alveoli         

stomach         

cerebrum         

nails         

nerves         

uterus         

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 Part 5: Verbal and written communication

1. List 5 routine tasks that a healthcare worker might undertake in a healthcare facility that would
require an effective understanding of medical terminology: (this could include interaction with
patients, fellow workers and health professionals)
(Please provide a short answer response to this question - 50 words or less)
1.Monitoring patients and documenting notes about the patient’s progress.

2.Doctors prescribing medications to their patients

3.During the coding and billing process

4.Professionals preparing to discharge a patient

5.During patient’s examinations

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 2. List 4 occasions it might be necessary to seek clarification/assistance from supervisors and
experienced staff members regarding the use of medical terminology?

(Please provide a short answer response to this question - 50 words or less)

1.In an emergency

2.When explaining a prescription or treatment to a patient

3.If you’re not familiar and unsure with the medical terminology

4.If you don’t know the pronunciation or the spelling

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 Part 6: Written communication

1. The role of a healthcare worker often involves receiving oral instructions, messages, and
records from clinicians and other allied health care professionals that need to be written down
and conveyed to the correct parties.  For this task you will be required to listen to the oral
report provided by a clinician. You need to transcribe what you hear into a written form in the

BSBMED301_AE_Kn
_1of2_SR1.m4a
space below. Double click on the icon to play the audio file to transcribe.

Transcribe below:
The pt is Mrs. Diane Nevil
72 yrs. old F
presented herself to the ER
1 week history of severe NVD and epigastric pain
Sent by Dr. Brown her family practitioner
Troubling Symptoms N&V, vomits everything she eats and drinks
Epigastric pains are tolerable, diarrhoea somewhat improve
The pt’s bowel movements are normal without history of black or bloody stools
Appetite down markedly, lost 1-2 kg in the last several days
Urination is normal
She is a social drinker and has a history of tobacco usage
On exam the pt appeared to be in moderate to severe distress appearing pale dehydration
BP lying 100/70, BP sitting 90/65, temp. 37 degrees, pulse 80 went 100 sitting up, R12
Admitted at least 23 hours hold and sent to be revaluated
Will receive fld. vol. replacement and pot. replacement
Electrolytes check as wells as blood count
Place on Zantac intravenously
Gastroscopy in the morning
Stools will be check if still loose for further out clot blood over impar site and possible C&S

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 Assessment Feedback
NOTE: This section must have the assessor signature and student signature to complete the feedback.

Assessment outcome
☐ Satisfactory

☐ Resubmission Required

☐ Unsatisfactory

Assessor feedback
☐ Was the assessment event successfully completed?

☐ If no, was the resubmission/re-assessment successfully completed?

☐ Was reasonable adjustment in place for this assessment event?

If yes, ensure it is detailed on the assessment document.

Comments:

Assessor name, signature and date

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