Medical Terminology, Records and Communication
Domain 8: Medical Terminology, Records and Communication
This domain tests word building, common abbreviations, legal documentation, consent, confidentiality and structured handover. Expect viva questions on what may or may not be written in a record.
Core rules
- Prefixes change meaning: brady- slow, tachy- fast, hyper- high, hypo- low, dys- difficult. Suffixes: -itis inflammation, -ectomy removal, -ostomy opening, -algia pain, -emia blood condition.
- Common orders: NPO nothing by mouth, stat immediately, BD twice daily, TDS three times daily, PRN when required, IM intramuscular, IV intravenous.
- Records must be accurate, timed, dated, signed, legible and factual; correct errors with a single line, initial and date-never erase or backdate.
- Consent must be informed and voluntary; confidentiality applies to all patient information.
- SBAR handover means Situation, Background, Assessment, Recommendation.
- Use only approved abbreviations from the clinical area.
Worked example
The term gastritis is built from gastr- (stomach) + -itis (inflammation), so it means inflammation of the stomach lining. Reasoning: identify the root and suffix, then state the meaning without adding a diagnosis.
Traps
Using unapproved abbreviations; leaving blank spaces; writing opinions as facts; discussing a patient in a corridor or on social media.