Medical Terminology, Documentation and Communication
This domain tests the language of healthcare, how a clinical record is written, and how to speak with patients and colleagues so nothing is lost.
Word building
Most medical terms are prefix + root + suffix.
- bradycardia = brady (slow) + cardi (heart) + ia (condition).
- tachycardia = fast heart rate; dyspnoea = difficult breathing; haematuria = blood in urine.
- gastritis = inflammation of the stomach; gastrectomy = removal of the stomach.
- hypertension = high pressure; hypoglycaemia = low blood sugar; arthralgia = joint pain.
Documentation rules
- Write in black or blue ink, with date, time and signature for every entry.
- Record facts, not opinions; quote what the patient says.
- Correct errors with a single line, write error, sign and date; never erase or overwrite.
- Use the 24-hour clock; record on the correct chart; never pre-chart.
- Avoid dangerous abbreviations such as U, IU, QD, QOD, MS and µg on their own.
Communication and handover
Use open questions, active listening, simple words, and an interpreter or family member where language differs. SBAR (Situation, Background, Assessment, Recommendation) is the standard handover format. Confidentiality applies to speech, screens and paper - discuss patients only with those involved in their care.
Worked example
The patient says, I feel dizzy. A careless entry reads: Patient is dizzy - that is subjective data presented as fact. Correct entry: Subjective: patient states, I feel dizzy. Objective: BP 96/60, pulse 104, skin warm and dry. Reasoning: subjective is what the patient reports; objective is what you measure or observe.
Traps that cost marks
- Writing an opinion such as patient is lazy instead of describing behaviour.
- Erasing or using whitener on a clinical record.
- Using unapproved abbreviations.
- Recording an entry before the event has happened.