Medical Terminology, Records and Communication
This domain tests whether you can decode medical words and prescriptions, write legally acceptable records, and hand over information accurately while keeping it confidential.
Core rules
- Word building: prefix + root + suffix. Roots: gastr (stomach), cardi (heart), nephr (kidney), hepat (liver), pulmon (lung), neur (nerve), oste (bone), derm (skin).
- Suffixes: -itis inflammation, -ectomy removal, -otomy incision, -ostomy opening, -algia pain, -emia blood condition, -uria urine condition, -megaly enlargement, -scopy viewing.
- Prefixes: tachy- fast, brady- slow, hypo- low, hyper- high, dys- difficult or painful, a-/an- without, peri- around, intra- within.
- Examples: gastritis = inflammation of the stomach; tachycardia = fast heart rate; dysuria = painful urination; nephrectomy = removal of a kidney.
- Abbreviations: OD once daily, BD twice daily, TDS three times, QID four times, HS at bedtime, AC before food, PC after food, SOS if required, STAT immediately, NPO nothing by mouth, PO by mouth, IV/IM/SC routes, TPR temperature-pulse-respiration, I/O intake-output, NKDA no known drug allergy.
- Records: OPD card, admission record, nurses' notes, TPR chart, intake-output chart, consent form, discharge summary. Write in ink, never overwrite; correct an error with a single line, your initials and the date; sign, date and time every entry.
- Communication: identify yourself, use simple language, listen actively, check understanding, keep confidentiality, and hand over using SBAR - Situation, Background, Assessment, Recommendation.
Worked example
Decode "Inj. Ceftriaxone 1 g IV BD". Reasoning: Inj. = injection; ceftriaxone is an antibiotic; 1 g is the dose; IV is the intravenous route; BD means twice daily - so it is given intravenously morning and evening.
Traps that cost marks
Overwriting or using correction fluid on a record; charting a procedure before performing it; inventing abbreviations not on the approved list; discussing a patient's diagnosis in a corridor.