Applying Medical Terminology Appropriately

In this section you will learn to:

• Use medical terminology appropriately when completing routine tasks
• Apply appropriate medical terminology as directed in oral and written communication with patients, fellow workers, and health professionals
• Present written communication to designated person for verification, if needed
• Spell and pronounce medical terminology correctly.

Supplementary materials relevant to this section:

• There are no associated reading for this section.

Now that you have a better understanding of medical terminologies and basic knowledge of working in a medical setting, you need to know how to apply this knowledge into your work. Depending on your specific work role and responsibilities, the tasks you need to complete may differ. However, the typical duties you are responsible for includes actioning routine tasks at the practice and maintaining oral and written communication with the stakeholders. We will begin this section of the Study Guide by looking at some routine tasks that you may carry out as a manager and look at some the oral and written communication tasks you may be assigned to.

Carrying Out Routine Tasks

The range of responsibilities you are expected to carry out depends on your specific role within the practice, and you may be expected to carry out administrative tasks in a medical practice. Often, they are routine tasks that involved many medical terminologies and hence you need a good command of the medical terminologies to provide quality care and service to the patients. This is so that the other party can understand what you said and what is required of them. Let us look at some common routine tasks that you may need to perform as a manager:

• Receiving visitors and patients: You are most likely the first face that a visitor or a patient sees upon arriving at your practice, and your professionalism and attitude would determine their impression of the practice. Some common expected behaviours are friendly and welcoming and be presentable and professional. Your workplace would have a set of procedure that you should follow, including how to greet the patients and what information you need from them before providing further assistance.
• Maintaining communal areas: It is crucial that communal areas that visitors and patients can access are maintained and kept tidy and clean. Not only does this minimise the risk of health and safety issues, but it also conveys the practice’s professionalism and that the patients can have a pleasant experience visiting the practice. This may include making sure the bins are not overflowed, no visible trash on the floor, the waiting area has clean and tidy seats, optimal temperature, cleaning and disinfecting surface areas, and more. Depending on your workplace’s protocol, some maintenance tasks need to be carried out in regularly intervals. Keep in mind that while cleaning is vital, if cleaning is done poorly or in the wrong way, it increases the risk of contamination (WorkSafe, 2018).
• Organising and maintaining information: Some practices will provide information and resources to patients, e.g., brochures, information booklet, post-operation care instructions, and service fees. These information needs to be reviewed and updated periodically to ensure that the most accurate information and knowledge are provided to the patients. Hence, it is vital that you are familiar with the correct medical terminologies used in these resources, otherwise patients are misinformed.
• Handling patient enquiries and complaints: Patients who are new to the practice would sometimes enquire about your practice such as the health practitioners available and service fees. Enquiries are usually made through phone calls, emails, and sometimes in-person. Hence, it is important that the correct medical terminologies are pronounced and spelled, e.g., the name of the procedure and the basic process of procedures.
  Sometimes, you may also need to handle complaints from patients, and this can range from dissatisfaction with their experience at the practice to unexpected out-of-pocket fees. Your workplace will have a complaints management handbook to guide their staff on how to handle and process these complaints. One thing to keep in mind is that all patients have their individual perspective in relation to their own health condition and how the services and care were delivered. Hence, you should view it as a source of information for you and your practice to improve service delivery.
• Storing and maintaining security of drugs: If your practice has drugs available, you may be responsible in storing the drugs in the correct manner, such as ensuring the drug is kept at the correct storage temperature. Maintaining the storage security of the drugs is also vital – you should store them in locked storage and are out of direct access to the public, especially children. This can minimise the risk of unauthorised individuals accessing the drugs which may lead to undesirable consequences.
• Ordering stock: Your role may include ordering a range of goods for the practice, including stationery and medical supplies. Your workplace should have a standardised order protocol, e.g., the supplier, how to receive goods, paying invoice, etc. To facilitate this, you should familiarise yourself with both the brand and generic names of products often used in your practice. For example, adhesive bandages are sometimes referred to as Band-Aid, which is a brand that produces bandages. It is important that you are familiar with the correct medical terminologies to ensure that the required goods are ordered, and the correct goods are received by the practice, so that the health practitioners can continue providing care to their patients.
• Contributing to meetings: You are usually expected to contribute at your practice’s meetings, such as giving feedback about service delivery and reviewing patient feedback and complaints about the practice.

Keep in mind that this list is not exhaustive and there will likely be other tasks that you are responsible for. Regardless, when you are carrying out these routine tasks, you should be mindful that your communication is addressed to the correct audience at the appropriate level. For instance, when replying to a patient’s enquiry, you would most likely use basic medical terminology or try to explain them in layman terms to avoid misunderstanding or confusion.

Further, it is extremely vital that you use the correct pronunciation and spelling of the medical terminology to avoid making mistakes. While some mistakes can be rectified immediately without severe consequences such as ordering the incorrect quantity of gauge, some mistakes can be dangerous and costly, e.g., incorrect patient symptoms were recorded, or incomplete care instructions are given to patients.

Using Checklists where Appropriate

After reading through the list of routine tasks you may need to perform, the long list may seem daunting to you. Or perhaps you are worried that you may miss out on a task which can lead to unwanted consequences due to legal requirements of maintaining certain record. This is when checklist comes in handy to help you keep track of routine tasks that need to be carried out. Most practices would have standard checklists for staff can refer to avoid making mistakes and disrupt the delivery of care, as well as maintaining the consistent quality of care delivered by different workers (Rege et al., 2020). Checklists also help medical workers during shift handovers to keep track of what tasks have been completed and yet to be completed to increase work efficiency and accuracy. These checklists typically outline the task that needs to be done, who is responsible for it, and when it should be completed. For example, opening and closing procedures, end-of-day financial reconciliation, and stock ordering.

Other than the standard checklists, throughout your day at work, you may have ad-hoc or unexpected tasks outside of the checklist. For example, your fellow worker requested that you follow up with a patient from two weeks ago, or the health practitioner asks that you set up a quote for a potential patient. This is when you can keep a separate checklist to record and monitor these unexpected or additional tasks. With this checklist, you can keep track of your own duty, what is left to do, and whether any follow-up action is required. Once a task is complete, it can be then crossed off. Below is an example of how this checklist may look like:

Other than keeping track of what was done and what needs to be done, the checklists also act as a record keeping device. With the completed tasks checked off, staff can refer to this checklist as needed. For example, keeping track of any required follow up action. Not only that, but your practice may also have a legal responsibility to maintain records about certain tasks such as drug order and stock management.

Seeking Assistance and Clarification

As mentioned in the previous section, if you have any confusion or do not understand any of the routine task, you must take initiative to speak up and seek assistance from your supervisors or more experience staff. Always clarify any doubts and seek clarity, and never carry out routine tasks without a clear understanding. If mistakes occur, you not only jeopardise the practice’s reputation but also putting the patient’s wellbeing at risk. That said, it should always be your responsibility to be as prepared as possible and make use of the sources of clarification instead of constantly approaching your supervisor for every single task.

As you should know by now, as a medical worker, you are expected to have frequent communication (both oral and written) with the stakeholders, e.g., fellow workers and patients. The remaining of this section of look at some common situations that are you expected to contribute; we will first look at oral communication then written communication.

Oral communication

As a medical worker, you will realise you need to communicate verbally with others frequently, including face-to-face oral communication and on the phone communication. The list below includes some of the most common situations that you will find yourself using oral communication:

• Answering patient’s enquiries: Patients may call your practice to enquire about the services provided by your practice and the associated fees. This also includes voicemails left by patients when the practice is unavailable to answer their enquiry immediately. There are also walk-in patients who might enquire about the practice’s services or if there are any available appointments. Typically, your practice will have a standardised response script that you can use to answer routine enquiries.
• Appointments: Depending on your practice’s protocol, some places remind patients about their appointments 48 hours prior and may require the patients to confirm their appointment. Hence, you may be tasked to phone the patient to remind and confirm about their upcoming appointment. Sometimes, patients may request to cancel or reschedule their appointment and may require your help to do so. Regardless, you need to make sure that you have the correct patient details and appointment time when doing so.
• Challenging patients or difficult enquiries: When you are communicating with patients, they may not always be feeling the best. As a result, you may have to deal with difficult or challenging patients from time to time such as nasty comments or asking for a refund. As briefly mentioned, your practice would have a complaints management handbook that you should adhere to when handling patients’ complaints. Your practice should have a similar guideline about handling challenging and/or upset patients. If you find the situation too overwhelming, consider seeking assistance from your supervisor. Further, if the patient becomes aggressive or verbally abusive, follow your practice’s protocol and if possible, remove yourself from the situation.
• Communicating information: This can occur in a few different forms – collecting and recording information from patients, relaying information to patients and their families, passing on messages or patient information to fellow workers and health practitioners. With patient’s consent, you might also need to convey or collect information from other practices (or departments) for referral information or further patient information. Other than patients and fellow workers, you may also liaise with organisations such as Medicare or private health insurance companies to handle patient claims.
• Getting in touch with health practitioners: You may need to communicate with other health practitioners regarding patient-related matters. For example, you may be assisting a patient to claim private health insurance but unsure which MBS item to invoice. Hence, you get in touch with their practitioner to confirm the MBS item. Depending on your workplace, if you work in a multi-department practice or hospital, you may need to transfer call to another department to better assist a patient. The health practitioner at your practice could also request that you page for someone else form another department to assist them.
• Instructions from supervisor or fellow workers: Other than your routine tasks, you may receive instructions from your supervisor to perform certain tasks. You may also receive requests from fellow workers to assist them with specific tasks around the practice.

Regardless of the nature of the oral communication, it is important that you are aware that you are using the appropriate medical terminologies when communicating, as well as the correct pronunciation is used. The latter is especially important, as incorrect pronunciation of medical terminologies would change the meaning of the information or message being relayed. Otherwise, it may lead to confusion or cause unintended harm to patients. For example, mispronouncing medication names when putting in an order with the supplier can lead to drastic consequences.

As mentioned, if you are unsure when receiving instructions, always check and confirm with the other person to make sure that you understand the correct information they are communicating. If you are relaying information to someone else, it is also part of your responsibility to make sure they receive the correct information. The other party assigns meaning to the message they receive, and it may or may not be the intended message you send (Karmin, 2016). One way to do so is to check whether they have a clear understanding about what you told them and clarify if needed. Another way to do so is to expand on your message to provide more context and information so that they have a clearer picture of the information you are trying to communicate.

Written Communication

Other than oral communication, you would also need to use appropriate medical terminology in written communication. This usually includes general correspondence found in the usual office correspondence and communication related to the medical context. Written communication can be in handwritten form such as letters and patient records or electronic form such as emails. Some common written communication includes:

• Forms: You may need to complete forms for different purposes. For example, forms for Medicare and private health insurance claims or bookings for specific medical equipment. When patients are completing forms, you should check with them that they have filled in the correct information such as their name and contact details.
• Office correspondences: You may be tasked to send memorandums before meetings and record meeting minutes, and compile and distribute the minutes to the relevant persons.
• Invoices and receipts: After receiving services, you will invoice the patients and provide receipt after payment. It is extremely important for you to make sure that all information is inaccurate, e.g., patient’s information, details of service received, outstanding fees, amount paid, and more. If any piece of information is incorrect, it may affect the insurance claims process.
• Appointments: Depending on your practice, they may use physical appointment cards for patients to keep track of their appointments. You would have to make sure that the correct appointment information is written down and are legible for the patients.
• Letters and documents: Sometimes you may need to prepare letters to patients, for example medical certificates and referral letters. You should make sure the information in the letters and documents are accurate and are issued for the correct patient.
• Correspondences with health professionals: Sometimes you may need to get in touch with other health professionals to exchange patient information or request for further information that may not be as urgent (which you would most likely use oral communication). This is when you need to make sure that your correspondence includes the correct patient information and the appropriate medical information.

Similar to clarifying the pronunciation of the medical terminologies, when you are communicating with others in written forms, you have to always make sure that you are using the appropriate terminologies, both medical and non-medical. For instance, you should be using terminologies with the correct English spelling to avoid confusion. If there is any written communication that involves handwritten materials, you should be aware that your handwriting is neat and legible so that the information communicated is clear.

Other than proofreading the documents yourself, you could also present the documents to a designated person for them to check, if required. For instance, if you are tasked to prepare a referral letter for a patient, you can present it to the health practitioner for verification prior to passing on the document. E.g., “Hi Jane, I was wondering if you could help me proofread a referral letter? It’s my first time writing one to a speech pathologist and I’m hoping you can have a look? Let me know if the letter is clear and whether more information is required! Thanks!”. Other than the health practitioner, you could also approach your supervisor or senior fellow worker to verify or clarify your work to prevent miscommunication or passing on inaccurate information to others.

Regardless of the form of communication, you always have to make sure that the appropriate terminologies are used and are conveyed in an appropriate manner. If in doubt, you should always check and clarify with someone else such as your supervisor or the health practitioner before proceeding. We would not want to put patients at risk or bring harm to others, including compromising the safety of fellow workers.

This section of the module outlined the common routine tasks that you may be responsible for at your workplace, such as receiving visitors and patients and organising and maintaining information. We also looked at how checklists can be a helpful tool for workers to carry out their daily routines. Next, we looked at how it is vital for managers to use appropriate medical terminology for communication, including oral and written communication.