• BSBMED301B - Interpret and apply medical terminology appropriately

Assessor Resource

Interpret and apply medical terminology appropriately

Assessment tool

Version 1.0
Issue Date: December 2023

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.

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.

You may want to include more information here about the target group and the purpose of the assessments (eg formative, summative, recognition)

Employability Skills

This unit contains employability skills.

Evidence Required

List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.

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

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.

Context of and specific resources for assessment

Assessment must ensure:

access to an actual workplace or simulated environment

access to office equipment and resources

examples of documentation and resources.

Method of assessment

A range of assessment methods should be used to assess practical skills and knowledge. The following examples are appropriate for this unit:

direct questioning combined with review of portfolios of evidence and third party workplace reports of on-the-job performance by the candidate

review of authenticated documents from the workplace or training environment

analysis of responses to case studies and scenarios

demonstration of techniques

observation of presentations

oral or written questioning

observation of performance in role plays

review of written communication with patients for use of appropriate medical terminology

oral or written questioning to assess knowledge of workplace emergencies, risks and hazards

assessment of documentation.

Guidance information for assessment

Holistic assessment with other units relevant to the industry sector, workplace and job role is recommended, for example:

other general administration or medical services administration units.

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assingnment, checklist) and due date here

Assessment task 1: [title]      Due date:

(add new lines for each of the assessment tasks)

Assessment Tasks

Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.

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.

The range statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Bold italicised wording, if used in the performance criteria, is detailed below. Essential operating conditions that may be present with training and assessment (depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts) may also be included.

Written and oral instructions may include:

diary entries

drugs orders

instructions for postoperative care


occupational health and safety (OHS) signs and instructions

patient notes


routine reports

telephone calls

test results

theatre lists

verbal instructions

Medical terminology may include:

abbreviations for medical and pharmacological terms (e.g. BCG, HRT, IVP, tab, ante, ung)

causes to changes in the systems of the body (e.g. changes to the musculo-skeletal system may include inflammation due to repeated strain on the system)

common medical conditions including illnesses, injuries and diseases

departments/sections in a hospital

health insurance terminology

interrelated functions of the body, locations and diseases (e.g. functions of the skeletal system, locations of skeletal injuries, skeletal diseases

knowledge of medical specialties and the names and titles of doctors working in specialist fields

medical conditions

medical equipment and instruments

medical investigations and procedures

Medicare terminology



terms to describe onset and/or nature of disease

Policies and procedures may include:

abiding by local, state/territory and commonwealth legislation

accessing and updating files

cleanliness and hygiene

correspondence format

emergency procedures

following instructions

information specific to the enterprise

office practice manual


Royal Australian College of General Practitioners (RACGP) Code of Practice for the Management of Health Information in General Practice

RACGP Entry Standards for General Practices

telephone protocol

recording information

security, confidentiality and privacy procedures

Clarification may be sought from:

drug and prescription information sources/databases

experienced staff member/s

medical dictionary

office practice manual

relevant handbook


Routine tasks may include:

answering patient enquiries

contributing to meetings

dealing with patient complaints

entering patient details into computer system

filing patient notes

maintaining information to assist patients

maintaining patient information

maintaining reception area, waiting room, consultation room

ordering stock (e.g. stationery, medical supplies)

preparing medical equipment

preparing reports

processing correspondence

producing a range of complex medical documents (e.g. patient history, case report)

providing information to patients

receiving and making telephone calls

receiving visitors and patients

recording information

storing and maintaining security of drugs

word processing

Oral communication may include:

answering routine telephone enquiries

communicating with a range of medical/hospital professionals on patient related matters

confirming appointments

dealing with difficult patients/customers

paging staff

reporting to staff at meetings

transferring calls

verbal instructions

Written communication may include:

appointment diaries, cards

case reports

complex correspondence to a range of medical/hospital professionals on patient related matters





patient histories

patient history questionnaires

patient records

telephone messages

Designated person may include:


practice manager


Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.

Observation Checklist

Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice Yes No Comments/feedback
Receive, interpret and document written and oral instructions using medical terminology 
Use checklists where appropriate 
Ensure own understanding of abbreviations for specialised medical terminology and associated processes 
Ensure own understanding of and adhere to, the policies and procedures of the enterprise 
Seek clarification when necessary 
Use medical terminology correctly in the completion of routine tasks 
Seek assistance from supervisor or experienced staff member as required 
Use appropriate medical terminology as directed, in oral communication with patients, fellow workers and health professionals 
Use appropriate medical terminology as directed, in written communication with patients, fellow workers and health professionals 
Present written communication to a designated person for verification if required 
Spell and pronounce medical terminology correctly 


Assessment Cover Sheet

BSBMED301B - Interpret and apply medical terminology appropriately
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Assessment Record Sheet

BSBMED301B - Interpret and apply medical terminology appropriately

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Assessment task 1: [title] Result: Competent Not yet competent

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