• BSBMED301B - Interpret and apply medical terminology appropriately

Interpret and apply medical terminology appropriately

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.


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.

Elements and Performance Criteria



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. Ensure own understanding of abbreviations for specialised medical terminology and associated processes

1.4. Ensure own understanding of and adhere to, the policies and procedures of the enterprise

1.5. Seek clarification when necessary

2. Carry out routine tasks

2.1. Use medical terminology correctly in the completion of routine tasks

2.2. Seek assistance from supervisor or experienced staff member as required

3. Use appropriate medical terminology in oral 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

Required Skills

Required skills

literacy skills to interpret policies, signs and instructions and to use correct spelling, grammar and punctuation

learning skills to research and increase own knowledge of medical terminology

communication skills to understand, clarify and explain instructions and procedures.

Required knowledge

medical terminology, including the fundamental word structure used in medical terms

basic systems of the body

organisational documentation and recording requirements

source of information relating to medical terminology

key provisions of relevant legislation from all levels of government that affects business operations, codes of practice and national standards, such as:

anti-discrimination legislation

ethical principles

privacy laws

Freedom of Information Act.

Evidence Required

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.

Range Statement

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

Written and oral instructions may include:

diary entries

drugs orders

instructions for postoperative care


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



Unit sector

Competency Field

Administration - Medical Services Administration

Employability Skills

This unit contains employability skills.

Licensing Information

Not applicable.