LA024995_BSBMED301_HCS_AE_Kn_1of3BaoxiaLi
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TAFE NSW - Sydney Institute *
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Course
CPCCBC4002
Subject
Health Science
Date
Feb 20, 2024
Type
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16
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Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: 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
316703844 Student name
Baoxia Li
Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: 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.
Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: 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 number 1 of 3
Instructions for this assessment This assessment is a combination of knowledge questions and case 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 instructions On completion of this assessment, you are required to upload it or 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.
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Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: Assessment details
Instructions
What do I need to do to achieve a satisfactory result? To achieve a satisfactory result for this assessment all questions must be answered correctly.
What do I need to provide? Pens or suitable electronic device. If this assessment is being used for online/distance delivery, the student must upload the assessment. What the assessor will provide? Access to resource available online & assessment audio-recording. Due date and time allowed As per the training plan Assessment feedback, review or appeals Appeals are addressed in accordance with Every Students Guide to Assessment.
Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: 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) Policies are the guiding principles of your organisation, Policies can be rules such as dress codes, conduct codes and so forth. They can also relate to procedures, outlining the procedure’s purpose and effectiveness measures
. Procedures are a particular way of doing something, usually outlined in a series of steps or a cycle to be followed to accomplish a result. 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) Recognised policies and procedures provide a consistent context within an organisation where and which to make decisions. There is a high-level risk of miscommunication and treatment disaster without standard policies and procedures in a healthcare practice. Medical terminology enables all health care individuals to communicate effectively without any error. As a result, every professional in the healthcare industry must understand and follow the policies and procedures that make it easier to work. 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)
Team meetings can be an excellent place to discuss, share or clarify any query about medical terminology terms that we have any difficulty understanding 2)
Providing a hard copy of Medical Terminology to every staff at the time of joining, periodically or when they are updated. 3)
Online training with a quiz session is another way of correcting the Medical Terminology among all staff 4. List 3 Legislative Acts that regulate the use of Medical Terminology:
Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: (Please list each Act –
no minimum word count required) 1. Privacy Act 1988 2. Human Rights and Equal Opportunity Commission Act 1986 3. Work Health and Safety Act 2011 (NSW) {You can refer to your online resources for further information} 5. 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) The correct action to be taken is to ask a more experienced colleague for assistance. Another way is to find the definition through the Internet, or we could also ask our superior or experienced staff to make sure that it is not possible for the patient. It is important to only use the correct pronunciation and spelling of medical terminology to avoid any miscommunication, misunderstandings, or errors. As well as being able to say and spell the medical term correctly, you would also need to ask a colleague to explain the meaning of this term. Another option to do this is to consult the procedure for medical terminology which should have the term in it, how to say it and what it means. You could further build on this understanding through a discussion with a colleague. 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)
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Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: The correct action is to ensure that all sensitive information is preserved. The privacy law states that no documentation or information is shown or shared with anyone else without the consent of the patient. otherwise, it is a violation of the law on privacy, and the practice and the staff member could be in serious trouble under the privacy act. The patient needs to give written and signed consent before their records can be shared with anybody. Health consumers in NSW have the right to access their personal information, but it cannot be shared with any other practitioner without the signed consent (NSW Health Records and Privacy Information Act 2002). This is usually simple and involves written request to your doctor looking for a copy of our clinical folder and organize the transfer to the new doctor. Regardless of what information in the medical care register, institutions must ensure that their processes & systems for documentation meet the requirements of the standard. This correctly involves the support of the workforce with documentation information and will include policies or training that clearly describe: - Roles, responsibilities, and expectations of the workforce in relation to documentation - When requested documentation - How to get access to records and health exemplars, verification lists or other tools and resources that support the documentation of best practices. 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) The checklist is necessary for a good guideline for everyone in a workplace is so that it
shows in detail the step-by-step instructions. Also put a routine for a team member to complete; it is the easiest way to get information across to a person. It also makes sures that a particular task is completed in a correct manner, and it will show that if someone must complete a section, they can see where they have gone wrong and fix it.
Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: Part 2: Abbreviation Assessment Task Please read the following sentences and provide the correct expanded medical term for each abbreviation N
OTE: 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 rate 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: coordination of benefits 3.
New admission to ward for R/V by the ENT Reg ASAP (Expanded medical term only required) R/V: Right ventricle ENT: ear, nose, and throat Reg: regular ASAP: as soon as possible
Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: 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: Referred M: Male Tx: Treatment #: Fracture 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 ∆
: Diagnosis Wt: Weight 3/12: three months 6.
Mr Wong has 2
o
burns and ++ ketones showing in his urinalysis: (Expanded medical term only required) 2
o
burns 2nd degree burns ++: two Plus positive or present 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: Right ventricle 6/7: number of days PO: per os or by mouth →: yields or becomes
+++: three Plus positive or present
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Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: 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: assistance with 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) I will ask my co-worker or superior if they are available to help. otherwise, I would go through a medical dictionary and reinforce that understanding through discussing it with a co-worker or superior at a later stage. I would ensure that I fully understand how to pronounce the word and exactly what it means. 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) The best way of learning medical terminology is by borrowing a medical dictionary and to study it. Frequently compare or communicate with available medical information with fellow workers or superiors will help you to remember the different medical terminology. You would also find information about medical terminology within the policies and procedures of the practice. Part 3: Basic Word Structure:
1.
List and describe the 4 fundamental elements of a medical term (No minimum word count) 1. Prefix - Word is located at the beginning of a term sentence to modify or change its meaning. 2. suffix - Word is placed at the end of a term sentence that modifies the meaning of the word. 3. root word - The root of a medical term usually has been borrowed from a Greek or Latin noun or verb. This root expresses the primary meaning of the term. Can be a central part of a word. 4. combining vowel - When we take a root word and add a vowel with it becomes a combined structure. This vowel is typically an ―
o, and it is called a combining vowel.
Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: 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 Root stomach hypo Prefix Low physis Prefix Losing or dissolving antero Prefix Before or earlier osis Suffix Disease or abnormal increase ial Suffix Pertaining to brady Prefix Slow bucc Root Affecting cheek or tongue genic Suffix Producing or causing pathy Suffix Disease or disorder phagia Suffix Eating or swallowing staxis Suffix Dripping or trickling metry Suffix Measurement pulmon Root Relating to lungs mast Prefix Relating to breast Sclerosis: Suffix hardening Part 4: Body Systems
Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: 1.
Using the following table, identify the appropriate body system for the following organs: (Please tick the appropriate box) Integu
mentar
y Respira
tory Nervou
s Cardiov
ascular Muscul
oskeleta
l Gastroi
ntestina
l Reprod
uctive Endocri
ne Lymph
atic trapeziu
s X epiderm
is X thymus X aorta X larynx X spleen X skin X bowel X alveoli X stomach X cerebru
m X nails X
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Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: nerves X uterus X 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.During surgery, a nurse, would need to use the proper medical terminology when locating something within the body; they might use the correct use of directional terms, e.g., along the Sagittal plane, to understand where to seek out the thing. 2. When a nurse explains what is happening to a client's body, they need to use the proper medical terminology and explain in simple words to understand fully 3. A surgeon explaining to a medico where something is to learn the medical terms, they could do that just before surgery. 4. A healthcare professional would wish to write down a report about the surgery to make sure it is kept in a secret place, and just in case, the patient would also sort of a copy and point out all the vital information about the surgery. 5. Between healthcare workers without the proper training and knowledge, information may confuse a patient's health and well-being 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)
Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: - If the context or meaning of a term is unclear. - You're reading a patient's chart, and you don't understand the diagnosis. - If you're giving a patient medication and don't know which one to provide - If you're giving a patient medication and you're not sure what to give them - if you're getting a handover from another HCW at the start of your shift. 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 space below. Double click on the icon to play the audio file to transcribe. Note: The patient’s name is spelt as Dianne Neville. You need to write ALL words in the medical story. Do not summarise the content. Expand ALL
abbreviations. Spelling needs to be correct. Use capital letters where appropriate e.g., people’s names are proper nouns and need a capital first letter. Set your answer out using paragraphs, commas, and full stops appropriately. Transcribe below:
Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: The patient is Mrs Diane Neville, 72-year-old female presented herself to the emergency room with a one-week history of rather severe nausea and vomiting and diarrhoea and epigastric pain. She was sent by doctor brown, her family practitioner. The most troubling symptoms for her are the vomiting and nausea because she vomits everything she drinks and eats. The epigastric pains are tolerable. Diarrhoea also is somewhat improved the patient’s
bowel movements usually are normal without history or black or bloody stools. Her appetite has been down markedly, and she has also lost at least one to two kilos in the last several days. Urination is normal. She is a social drinker and has a history of tobacco usage. On examination the patient appeared to be in moderate to severe distress appearing pale with dehydration. Blood pressure lying 100 / 70 pressure 90 / 65, temperature 37 degrees, pulse 80 went to 100 on sitting, up respirations 12. The patient will be admitted at least for a 23 hour hold and is then to be re-evaluated and will receive fluid volume replacement and potassium replacement she will have her electrolytes checked as well as her blood count and will also be placed on Zantac intravenously. She will then have a gastroscopy in the morning her stools will also be checked if they're still loose for further occult blood over in parasites and a possible culture and sensitivity
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Document title: BSBMED301_HCS_AE_Kn_1of3 Page 1 of 19 Resource ID: HCS_18_22_BSBMED301_HCS_AE_Kn_1of3 STUDENT NAME: 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