Application

This unit describes the performance outcomes, skills and knowledge required to apply an understanding of medical terminology to interpret clinical documentation and communicate with health care professionals.
This unit applies to health care professionals who are responsible for interpreting patient clinical information for the purposes of providing health care services. Work may be performed as an individual or as part of a team under limited supervision.
The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian standards and industry codes of practice.
No occupational licensing, certification or specific legislative requirements apply to this unit at the time of publication.

What You'll Learn

Assessment Requirements

Performance Evidence

Evidence of the ability to complete tasks outlined in elements and performance criteria of this unit in the context of the job role, and:
• use accurate medical terminology, clinical abbreviations and acronyms in at least one oral and one written communication relating to each of the following:
• infectious and parasitic diseases
• neoplasms
• diseases of the blood and blood-forming organs and disorders involving the immune mechanism.
• endocrine, nutritional and metabolic diseases
• mental and behavioural disorders
• diseases of the nervous system
• diseases of the eye and adnexa
• diseases of the ear and mastoid process
• diseases of the circulatory system
• diseases of the respiratory system
• diseases of the digestive system
• diseases of the skin and subcutaneous tissue
• diseases of the musculoskeletal system and connective tissue
• diseases of the genitourinary system
• pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities
• symptoms, signs and abnormal clinical and laboratory findings
• injury, poisoning and causes of morbidity and mortality.

Knowledge Evidence

Demonstrated knowledge required to complete the tasks outlined in elements and performance criteria of this unit:
• medical terminology for interpretation of clinical documentation and communication with clinical health care professionals.
• constituent parts of medical terms including prefixes, suffixes, roots, combining vowels and combining forms
• clinical abbreviations and symbols
• differences between clinical and diagnostic terminology
• roots, suffixes and prefixes used for:
• infectious and parasitic diseases
• neoplasms
• diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
• endocrine, nutritional and metabolic diseases
• mental and behavioural disorders
• diseases of the nervous system
• diseases of the eye and adnexa
• diseases of the ear and mastoid process
• diseases of the circulatory system
• diseases of the respiratory system
• diseases of the digestive system
• diseases of the skin and subcutaneous tissue
• diseases of the musculoskeletal system and connective tissue
• diseases of the genitourinary system
• pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities
• symptoms, signs and abnormal clinical and laboratory findings.

Assessment Conditions

Skills must be demonstrated in the workplace or in a simulated environment that reflects workplace conditions.
Assessment must ensure access to:
• real-life patient health care records or de-identified real patient health care records either electronic or hard copy, that reflect current clinical practice
• modelling of industry operating conditions, including:
• integration of situations requiring problem solving
• organisational policies and procedures
Assessors must satisfy the Standards for Registered Training Organisations’ requirements for assessors.

Foundation Skills

• {'skill': 'Foundation Skills', 'description': 'Foundation skills essential to performance are explicit in the performance criteria of this unit of competency.'}

Related Units

• HLTAID011 — Provide First Aid
  Same training package
• HLTAHCS005 — Implement basic health care plans
  Same training package
• HLTAID003 — Provide first aid
  Same training package
• HLTHPS009 — Perform peripheral intravenous cannulation
  Same training package
• HLTOTH007 — Apply and remove traction
  Same training package
• HLTAHCS002 — Assist with health assessments
  Same training package