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Unit of competency details

HLTCCD003 - Use medical terminology in health care (Release 2)

Summary

Usage recommendation:
Current
Release Status:
Current
Releases:
ReleaseRelease date
2 (this release) 02/Jul/2021
(View details for release 1) 30/Apr/2021


Classifications

SchemeCodeClassification value
ASCED Module/Unit of Competency Field of Education Identifier 080313 Public And Health Care Administration  

Classification history

SchemeCodeClassification valueStart dateEnd date
ASCED Module/Unit of Competency Field of Education Identifier 080313 Public And Health Care Administration  15/Jun/2021 
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Unit of competency

Modification History

Release 

Comments 

Release 2

Release 2 HLTCCD003 Use medical terminology in health care supersedes and is equivalent to Release 1 HLTCCD003 Use medical terminology in health care.

Updated:

Mapping details and minor corrections

Release 1

HLTCCD003 Use medical terminology in health care no equivalent unit.

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.

Pre-requisite Unit

Nil

Competency Field

Clinical Coding

Unit Sector

Health Administration

Elements and Performance Criteria

ELEMENTS 

PERFORMANCE CRITERIA 

Elements describe the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Identify medical terms used in clinical documentation.

1.1. Analyse and interpret medical terms by identifying and dividing into constituent parts.

1.2. Build medical terms using constituent parts.

1.3. Interpret clinical abbreviations and acronyms in clinical documentation.

2. Communicate using medical terminology.

2.1. Document medical terms accurately, including singular and plurals of medical terms.

2.2. Articulate medical terms correctly.

2.3. Use appropriate medical terminology in written and oral communication.

3. Identify health status of patients.

3.1. Interpret medical terminology to identify sources and types of information in patient health care records.

3.2. Analyse patient health care records applying an understanding of medical terminology to determine reason for episode of care.

3.3. Analyse patient health care record applying an understanding of medical terminology to determine surgery and intervention performed.

Foundation Skills

Foundation skills essential to performance are explicit in the performance criteria of this unit of competency.

Unit Mapping Information

No Equivalent Unit

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705

 

Assessment requirements

Modification History

Release 

Comments 

Release 2

Release 2 HLTCCD003 Use medical terminology in health care supersedes and is equivalent to Release 1 HLTCCD003 Use medical terminology in health care.

Updated:

Mapping details and minor corrections

Release 1

HLTCCD003 Use medical terminology in health care no equivalent unit.

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.

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705