Medical terms Flashcards
Interpret and apply medical terminology appropriately
Prefix:
denotes size, shape, colour, direction or amount
Suffix:
Size/shape/colour, or disease/disorder/procedure
sarco- :
muscle
contra- :
against
(12) Healthcare settings you might read, write or hear medical terms in:
Routine reports; Referrals; Pre- and Post-op care instructions; Drug orders; Diary entries; Client notes; WHS signs/instructions; Verbal instructions; Test results; Notices/memos; Phone calls; Theatre lists
Time used in medical communication:
24hr clock (2330 = 11:30pm) 7/7 Seven days (i.e. one week) 3/7 In three days 1/7 In one day 1/52 In one week 6/52 In six weeks (e.g. Mrs Smith requires an outpatient appointment in six weeks’ time.) 1/12 One month 12/12 12 months
ICU: HDU: CCU: OT: ENT: O and G: OPD: ED: CSSD: PCC:
Intensive Care Unit High Dependency Unit (very sick patients) Coronary Care Unit (high risk cardiac patients) Operating Theatres Ear, Nose, Throat Obstetrics and Gynaecology Outpatients Department Emergency Department Central Sterile Supply Department Person Centred Care
Orthopaedic:
Paediatrics:
Aged Care Funding Instrument (ACFI):
Specialises in conditions of the bones
Children
The ACFI is a funding tool used to appraise a resident’s need for care. The tool are activities of daily living (ADL), behaviour (BEH) and complex health care (CHC)
s/b: c/o: Dx: Hx: Rx:
seen by complained of diagnosis history treatment
Inj: IV: IM: SC: IVT:
injection intravenous intramuscular subcutaneous (often refers to injection type) intravenous therapy (usually refers to an intravenous infusion)
PHx:
HPC:
O/E:
PRN (or p.r.n):
past history
history of presenting condition
on examination
pro re nata (Latin) (often refers to taking/giving medication as needed, e.g. for pain)
Why do we need to consider context?
There are numerous medical terms and abbreviations. They can have more than one meaning, depending on the body system or the procedure being referred to.
E.g:
PO can mean ‘Pulmonary Oedema’ if it refers to the respiratory system.
or
‘Per oral’ if it refers to medicine administration
Where can you find definitions for new terminology?
Apps: Medical Dictionary Offline (Android)
Oxford Concise Medical Dictionary(Apple)
MedicineList+ (Android/Apple)
Internet: medilexicon.com
medword.com
medlineplus.gov
australia.gov.au/information-and-services/health/medicine-and-health-products
Head and neck bones:
skull: cranium
mandible (jaw bone)
cervical vertebrae
Thoracic cavity bones:
clavicle (collar bone)
manubrium (joins 2 clavicles, just above sternum)
sternum (joins ribs at anterior side)
ribs
thoracic vertebrae (segment of spine through ribs)
Abdominopelvic cavity bones:
lumbar vertebrae (segment of spine inferior to ribs)
sacrum (where spine joins hips/pelvis)
coccyx (tailbone)
pelvic girdle
Arm bones:
scapula (shoulder blade) humerus (proximal arm bone) radius (upper [thumb side] distal arm bone) ulna (lower distal arm bone) carpals (wrist bones) metacarpals (bones through palm) phalanges (finger/toe bones)
Leg bones:
femur (proximal leg bone) patella (knee) tibia (inside distal leg bone) fibula (outside distal leg bone) tarsals (ankle bones) metatarsals (bones through body of foot) phalanges (toe/finger bones)
Terms relating to skeletal system: arthr(o): articular: osteo-: -arthr: -itis: -por-(o): -osis: peri-
. joints, limbs, bones joint relating to bone relating to joints inflammation porous condition of around
Terms relating to skeletal system: OA: AKA: TKR: ROM: #:
. osteoarthritis above knee amputation total knee replacement range of movement fracture
Terms relating to skeletal system: BKA: Fx: Ortho: PHx: HPC: O/E:
. below knee amputation fracture orthopaedics past history history of presenting condition on examination
Paget disease:
people with Paget disease of bone have unusually thick bones, but they are soft and prone to break because of their abnormal structure
Osteomalacia:
Also known as rickets.
A condition in which Vitamin D deficiency disrupts normal bone formation
Infectious diseases that affect the skeletal system:
Osteomyelitis describes a bone infection, usually caused by bacteria.
Septic arthritis is a joint infection, which is also typically caused by bacteria but is sometimes due to a virus or fungus.
Certain bacterial infections of the intestine or reproductive system can also affect the joints, a condition known as reactive arthritis.
Joint inflammation and arthritic pain are also common with infectious illnesses like Lyme disease, chronic hepatitis C and infectious mononucleosis.
ligaments:
tendons:
attach bone to bone, and help stabilise joints.
attach muscle to bone.
Nervous system components:
including specific nerves
brain
spinal cord
arm nerves: median nerve
radial nerve
ulnar nerve
leg nerves: sacral nerve
sciatic nerve
saphenous nerve
tibial nerve
thoracic nerves
pudental nerves
lumbar nervesParts of the brain:
Frontal lobe parietal lobe (upper back section) occipital lobe (lower back section) temporal lobe (lower front/mid section) cerebellum (base) meninges (membranes wrapping brain and spinal cord) cerebrospinal fluid
spinal cord
Terms relating to nervous system: cerebr(o)- crani dis- dys- hemi-
. relating to the brain of the skull taking apart difficult/painful/not working properly half
Terms relating to nervous system: isch- mening- -plegia -paresis vascular
. restriction of the meninges paralysis weakness of blood vessels
Terms relating to nervous system: Neuro: CVD: ICP: LP: CSF: EEG:
. neurology cerebrovascular disease intracranial pressure lumbar puncture cerebrospinal fluid electroencephalogram (measures/records electrical activity of the brain)
Terms relating to nervous system: PD: PNS: PTSD: TIA: CVA: LOC:
.
Parkinson's disease
peripheral nervous system
post-traumatic stress disorder
transient ischaemic attack (a transient form of 'stroke')
cerebrovascular accident ('stroke')
loss of consciousnessCirculatory system also known as:
cardiovascular system.
or CVS
Terms relating to circulatory system: cardia/cardiacus: a-: -aem: -ia: ather(o)-:
. of the heart without/deficient (arrhythmia) of blood condition of plaque or fatty substance
Terms relating to circulatory system: sclerosis: -tension: infarct: -(i)al stenosis:
. harden pressure plug up/cram condition tightening, stricture
Terms relating to circulatory system: c/o: H/O: M.I: IHD: CVD:
. complained of history of myocardial infarction, or 'heart attack' ischaemic heart disease cardiovascular disease
Terms relating to circulatory system:
CVS:
AAA ("triple A"):
AF:
CABG (pronounced "cabbage"):
CO:.
cardiovascular system
abdominal aortic aneurysm (weakness in wall of aorta)
atrial fibrillation (a heart dysrhythmia)
coronary artery bypass graft
cardiac output
Terms relating to circulatory system: ECG: HR: FU (or F/U): VT: VF:
.
electrocardiogram (traces electrical activity of the heart)
heart rate (beats per minute)
follow up
ventricular tachycardia (a fast heart rhythm)
ventricular fibrillation (fast heart rhythm that may be fatal)
Components of respiratory system:
nostrils nasal cavity pharynx epiglottis larynx trachea bronchial tubes bronchioles alveoli (air sacs at the end of the bronchioles) lungs pleural membranes intercostal muscles diaphragm
Terms relating to respiratory system: ex- : laryng/o : pharyng/o : -oscopy : pneum- : trache : -ostomy :
. out of of the larynx of the pharynx use of an instrument to view of the lungs of the trachea make an artificial opening
oximeter
instrument to measure oxygen saturation
Terms relating to respiratory system: ABG: COPD: PO: SOB: SOBOE: Sp02 Sa02 Oxygen sats:
.
arterial blood gas (measurements from blood tests)
chronic obstructive pulmonary disease
pulmonary oedema (fluid in the lungs)
short of breath
short of breath on exertion
All relate to the measurement of oxygen in the blood, often by means of an oxygen saturation monitor that can be attached to the fingers or toes
Terms relating to respiratory system: RR: obs/vital obs: CXR: PA CXR: Supine CXR film: Lateral CXR film:
.
respiratory rate (the number of breaths in a minute)
vital observations (ie temperature, BP, HR, RR, Sp02)
chest X-ray
Posterior Anterior Chest X-ray (the normal CXR view)
Chest X-ray taken with patient lying on his/her back
Chest X-ray taken from the side
Three divisions of the skin:
the epidermis, the dermis, and the hypodermis (or subcutaneous) layers.
Terms relating to integumentary system: Adip(o)- : Cutane(o)/cutis : Derm(o)/dermat(o) : Diaphor(o)-: Lip(o)- : Cyan(o)- :
. fat of skin skin profuse sweating fat blue
Terms relating to integumentary system: Hypo- : Leuk(o)- : Melan(o)- : -oma : -plasty : Py(o)- : Epi- : Sub- :
. under or below white black growth/tumour surgical repair pus over or above under or below
Terms relating to muscular system: a- or an- : -trophy : dys- : -itis : tri : quad : -ceps : my(o)- : -algia : -asthenia :
. without growth difficult/painful inflammation three four heads/attachments muscle pain weakness
Terms relating to muscular system: CTS: RICE: ACL: EMG:
ADL:
.
carpal tunnel syndrome
Rest, ice, compression, elevation (muscle injury first aid)
Anterior cruciate ligament (knee ligament)
Electromyography (measurement of the electrical activity of skeletal muscles)
Activities of daily living (a measurement of independence of a person)
Terms relating to digestive system: chole- : cholecyst : -al : -(o)tomy : -itis : -ectomy :
. bile (stored in gallbladder, hence: ) gallbladder pertaining to surgical cutting inflammation removal of
Terms relating to digestive system: -emesis : ex- : gastr(o)- : -stomy : periton(is) :
. vomiting out of/away stomach artificial opening abdominal membrane
Endocrine system (top to bottom):
hypothalamus pituary gland (in front) pineal gland (behind) thyroid and parathyroid glands thymus pancreas adrenal glands gonads (ovaries/testes) placenta, if pregnant
Terms relating to endocrine system: -aem, haem : anti- : end-(o) : hormon : hyper- : hypo- : -ism : secret (io) :
. blood against within sets in motion increased decreased condition of to separate
Terms relating to endocrine system: BMR: Bx: DM: Dx: DKA:
. basal metabolic rate biopsy diabetes mellitus (Type I or II) diagnosis diabetic ketoacidosis
Basic urinary system (top to bottom):
veins & arteries kidneys ureters (one from each kidney) bladder nerves (one to sense when full; one to instruct release) muscle urethra
Terms relating to urinary/excretory system: ren(es) : cyst(o)/cyst(i) : calculus : lithiasis : -logist : nephr(os) : supra- : -uria :
. of kidneys of the bladder little stone formation of calculi one who studies of kidneys above of urine
Terms relating to urinary/excretory system: ACE: ARF: CRF: K / K+ : UTI:
. Angiotensin Converting Enzyme (see ACE inhibitors) acute renal failure chronic renal failure potassium urinary tract infection
Terms relating to urinary/excretory system: GU: H20: Na / Na+ : UA: IVP:
. genitourinary system water sodium urinalysis intravenous pyelogram
Female reproductive system:
ovary fimbria (finger-like fringe at edge of fallopian tube) (fimbriae = plural) fallopian tube fundus uterus endometrium myometrium cervix vagina
Male reproductive system:
testicle epididymus ductus deferens urinary bladder seminal vessicle ejaculatory duct prostate gland glans penis penis
Terms relating to reproductive system: -metr : gyn-(aec)(o) : C-section / CS : D and C : CA: Gyn:
. of the uterus of women caesarean section Dilation and curettage cancer gynaecology
Terms relating to reproductive system: IUD: IVF: LMP: Para: Grav: STD:
.
Intrauterine device (contraceptive device)
In vitro fertilization (vitre (o) = glass)
last menstrual period
number of times a woman has given birth (Para=2)
gravida (number of pregnancies) e.g. Grav 3
sexually transmitted disease
Where can you find exactly what routine tasks you are personally responsible for at work?
In your Job Description
Some possible examples of routine tasks you may be required to do:
Filing records, notes, and everyday correspondence;
Ordering stock, storing, maintaining security of medication;
Communicating/responding to client enquiries (phone, in person and email);
Dealing with complaints;
Keeping the reception/waiting areas clean and tidy;
Entering client details/data and keep information current;
Preparing medical equipment;
Contributing to meetings and recording information;
Examples of stock to be ordered:
Stationery: Pens, pencils, rulers, notepads, phone message pads, printing paper, rubber bands, paper clips etc.
All types of new and replacement medical equipment and supplies such as beds, trolleys and chairs.
Medicines, wound care supplies are ordered by RNs.
Cleaning supplies: Floor cleaner, bathroom/toilet cleaning equipment, general purpose cleaners, mops, buckets
Replacements for stock that is either out of date stock or has been used, e.g. sterile scissors, sterile forceps
Tea/coffee/biscuits for staff and/or patients and visitors
Guidelines for ordering stock:
Use the correct form Write legibly Use appropriate medical terms Spell correctly Date and sign, and print your name and designation
Or: depending on your organisation, you might order stock using the intranet (your organisation’s internal website).
Every organisation has its own format for ordering stock so you will need to ask a supervisor for information about this task. When you have completed an order for the first time, ask a senior colleague to check the order – it is easier to make corrections rather than having the order form returned or not filled
Examples of equipment in a physiotherapy or occupational therapy setting include:
Postural Supports; Ankle Instabilities; Patellofemoral; Dysfunction; General knee pathologies (e.g. OA); Lumbar and pelvic supports; Moderate to severe knee arthritis knee braces; Custom fit walker boots and post-op hinge knee braces; Orthotics
Effective oral communication is important because:
Some examples of oral communication:
Staff working in a healthcare setting have to use their time very efficiently.
It is vital that your oral communication is professional, respectful and facilitates good relationships.
You must use appropriate medical terminology that reflects the needs of the clients and encourages timely responses to care.
Receiving/transferring telephone enquiries;
Talking to staff and other health professionals;
Confirming appointments;
Paging staff;
Discussing topics at meetings;
Receiving or giving instructions.
Steps towards effective oral communication :
Think about the space you are in and whether more privacy is required for the conversation;
Maintain the dignity/privacy of the person you are communicating with or anyone else you may be discussing and consider your surroundings;
Ensure your message has a purpose;
Think before you speak;
Use positive body language;
Eliminate unnecessary words; keep th message simple;
Keep communication appropriate to the receiver;
Speak at a medium pace;
Use clear, correct pronunciation, inflection, tone and volume.
Why is communication in
healthcare important?
Improve overall satisfaction and contribute towards better long-term health outcomes.
Level of understanding of information provided can impact on future healthcare decisions.
Lack of understanding may increase risk of instructions being followed incorrectly, or an adverse event occurring.
“Communication and information systems” is the
third most common type of health service complaint received by the Office of the Health Ombudsman.
The most common communication complaints are
in relation to:
Poor attitude or manner; Providing inadequate information; Providing incorrect or misleading information; Not accommodating special needs .
Taking phone messages:
Be professional, empathic and speak slowly and clearly as caller may be feeling stressed etc (phoning health facility)
Make sure you know where your department/organisation’s telephone list is.
Smile: people hear it.
Take a full and accurate message. Include : who the message is for; date and time of call; name and contact details of caller; what the message is; your name/signature
Ask the person to repeat themselves if you’re unsure of anything.
Repeat the entire message to the caller to ensure that you have the correct information.
If there are medical terms you don’t know, ask for the words to be spelt out so that you have an accurate record of the conversation.
Four steps to active listening:
Attentive (positive) body language;
Eye contact (unless inappropriate);
Ask open questions to get more information;
Repeat in your own words (rephrase) what you think you’ve heard.
What should you do if you see someone in your area you haven’t seen before?
Introduce yourself by name, smile and ask if you can assist them. Apart from being helpful, it helps maintain the security of the healthcare environment as it’s inappropriate to have unknown people in a restricted area.
Healthcare settings can be stressful for members of the public, who are out of their normal environment and may be facing a health crisis.
Show new clients to their room when they present to the ward for the first time or to a waiting area. First impressions are important and can influence the ongoing relationship between patient, relatives and staff.
Active listening techniques (cycle of 5)
Noting content; Perceiving emotions; Exhibiting empathy; Observing cues; Restating information; ---> noting content etc
DOs and DON’Ts of active listening:
Do:
Enquire about their needs, concerns and anxieties.
Use questions that encourage them to open up.
Ask and check that you understand them.
Don’t:
Don’t talk about yourself.
Don’t change the topic.
Don’t ignore or deny feelings.
Keeping healthcare records up to date:
Any staff member who is informed of new contact details for patients or next of kin, should confirm the information, then change and date the records to maintain accurate details.
You might forward results from tests and investigations to the patient’s ward, department or GP in hard- or softcopy. Enter all results in the patient’s chart as soon as possible. If this task is part of your role, file the results in the:
correct person’s chart
correct format
same way as other similar results in the chart.
This ensures that your colleagues are able to find the information when it is required.
Info likely to be included in patient files:
Name, DOB, marital status, address, ph number etc;
Next of Kin details;
Patient history (inc. history of current condition/issues, other health issues, and previous records);
Allergies/sensitivities (food, medication, dyes etc);
Current medications;
Referral letters;
Case record: notes relating to current health issue;
Results from investigations (xrays, ECGs, blood tests etc);
Any other relevant info
Always have the correct patient chart in front of you:
as filing notes in the wrong patient’s chart can have far-reaching and potentially disastrous consequences.
Scheduling appointments:
In a medical practice:
usually in an appointment book
lists all the patients who wish to consult with the doctor or doctors at specific times in the day.
Ensure that the writing in these diaries is legible! Appointment diaries may also be on the computer in a variety of formats.
In a hospital:
When an appointment is arranged with another department or person, it should be written in patient’s progress notes and on their clinical pathway to alert other staff of the proposed event.
Some wards may have a diary/whiteboard for appointments. Keep these out of the sight of other patients and visitors! (privacy and confidentiality)
Check diary each morning. Notify staff members involved.
Appointments for inpatients generally don’t have to be confirmed, but if there is an appointment at another location or site, phone confirmation may be required.
Attending meetings:
Could be Work Health and Safety, ward or department staff or union meetings.
May also be asked to attend case conferences (group of healthcare providers discuss particular patients’ issues). Sometimes, the patient or their relatives may be present. If asked to join the conference, you would not be expected to talk but to make accurate notes of what was said.
Taking minutes for meetings:
what are they? who can view them? what do they contain?
A written document of the items discussed at a meeting.
All staff might be able to view these but sometimes the information will be confidential and privacy must be maintained, for example during performance management of a staff member.
Minutes will contain information on:
• the date and time of the meeting, sometimes location.
• attendees and apologies for absence
* review of previous meeting minutes, and any action taken
• items discussed and decisions made.
Minutes should be succinct, they do not need to be an individual record of what each person said, rather a summary of topics discussed and actions taken or agreed upon.
Examples of checklists:
can cover a variety of areas from clinical care, for example:
a peri-operative checklist, or a client completed tick sheet regarding their current health status.
A checklist is a step-by-step worksheet used in a clinical setting.
It safeguards against incidents and minimises risk to clients.
When completing a checklist allow yourself sufficient time to complete the form to ensure all relevant information is obtained.
You should:
• tick all the boxes that apply
• signature, name and date of person completing the form must be legible.
Ways you may have to deal with written correspondence:
Writing letters or memos on word processing programs
Retrieving correspondence from computer or file
Filing correspondence in the correct patient’s file
Forwarding correspondence to another person (‘third party’)
To ensure you do this effectively and professionally:
Be familiar with word processing programs;
Type accurately;
Use correct grammar, punctuation, and spell-checker;
Use a medical dictionary and terminology reference.
If you are asked to write a letter on another person’s behalf:
Always give the final version to this person for verification and signing so that it can be reviewed and changed if necessary before being sent out.
When recording any type of client-related information, be concise and factual.
Why/how?
A report you write is a document that can be used in a court of law.
If you are unsure of what to write or are unsure of medical terminology, consult with an RN or Supervisor before you begin writing the report and ask them to check over your completed entry.
If you make a mistake on an entry, simply cross through it, initial the error and continue your entry.
White Out and correction pens must never be used in a healthcare setting.
Each entry must record the date and time, your signature and printed name and designation.
Before you complete any documentation, always make sure you have the correct patient identifier on the paperwork. Check if your documentation requires countersigning at your facility.
Policies and procedures manual will/must:
Be familiar to you (know its content).
Be specific to your facility or area.
Be followed to ensure safe and legally responsible care.
Contain the answers to most questions about acceptable procedures.
Be collated to incorporate local, state, territory and Commonwealth legislation and regulations.
It might also include checklists and specific tasks for each work role.
Can include info on:
Workplace discrimination
Workplace Health and Safety (WHS)
Emergency procedures (workplace signage, PPE, etc)
Privacy and confidentiality
Telephone protocol and recording information
Standards for General Practice
Anti-discrimination legislation in Australia:
If you treat someone unfairly because of the group they belong to, you are discriminating against them.
The Anti-discrimination Act 1975 (Commonwealth) makes all types of discrimination unlawful in Australia including race and disability.
Its aim is to ensure that people’s human rights and freedoms are protected, irrespective of their age, race, sex or disability.
The aim of Work Health and Safety (WHS):
To ensure that every employee is at the lowest possible risk of disease or injury at work.
The Work Health and Safety Act (2011) says that while at work, a worker must co-operate with any reasonable policy or procedure related to health and safety in the workplace.
(4) Key principles employers, employees and authorities should comply with:
(regarding WHS)
All people should be given the highest level of protection against risks to their health and safety that is reasonably practicable in the circumstances.
Any person who manages, owns or controls workplaces is responsible for eliminating or reducing those risks so far as practicable.
Employers and self-employed persons should be proactive and take reasonably practicable measures to ensure health and safety.
Employers and employees should exchange information and represent their ideas about risks to health and safety and the measures that can be taken to eliminate or reduce those risks.
Standard precautions for infection control:
these exist to prevent cross infection
Effective hand hygiene remains one of the most important strategies for preventing cross infection and should be used frequently by all staff working in healthcare.
Staff should use Alcohol Based Hand Rub (ABHR) as indicated by Hand Hygiene Australia.
5 Moments for Hand Hygiene:
in clinical settings
Before touching a patient; Before a procedure; After a procedure or body fluid exposure risk; After touching a patient; After touching a patient's surroundings.
Emergency plans:
Emergencies cover a number of situations in a healthcare setting and it is vital that you attend regular training.
Be aware of alarms, security codes and emergency response numbers so that you can act quickly during an emergency.
Be able to:
Locate spill kits;
Locate safety data sheets (SDS);
Take part in evacuation scenarios and understand the concepts of safe evacuation and containment;
Locate, use and replenish first aid kit (with training);
Locate and use PPE;
Recognise/implement safety procedures for safety signs.
Patient confidentiality:
Strictly regulated and based on the premise that the public has a right to expect that the information held about them will remain private.
An example of legislation governing privacy is the Information Privacy Act (2009) .
Keeping information confidential and private within healthcare:
(5 points)
Passwords must be kept private, not shared and be changed regularly;
Do not discuss your work or cases over the internet in such areas as Twitter, Facebook or email. It is a breach of confidentiality even if the client is not named;
Do not give any personal information regarding the client over the phone without checking with the client and a senior nurse;
Do not discuss the client with anyone (including the police) other than those who are directly involved with the client’s care;
Do not release private phone numbers to anyone – this includes staff, visitors and clients, this is a serious breach of privacy.
Telephone protocol and recording information:
When you speak to a client, carer, guardian or advocate on the telephone, document this in the appropriate notes, including the time and date.
If the person cannot speak on the phone, do not relay information to any other party unless the person has given their consent. Clearly document the consent, noting the person’s identity each time they phone your organisation.
It is not illegal to record a conversation. However, from a professional standpoint you should make the other party aware that you are.
It is illegal to communicate or publish the recorded conversation without the permission of those involved in the conversation.
Observing confidentiality and privacy:
Do not discuss client information outside of work such as at the local coffee place. Make sure you are in a secure environment at work when talking about issues related to your work;
Do not discuss your work or cases over the internet in such areas as Twitter or Facebook or email. It is a breach of confidentiality even if the client is not named;
Do not give any personal information regarding the client over the phone without checking with the client and a senior nurse;
Do not discuss the client with anyone (including the police) other than those who are directly involved with the client’s care;
Do not allow health care staff who are not directly involved in the client’s care management to access any information regarding the client.
Freedom of Information legislation:
Specific laws related to accessing medical records in Australian states and territories.
Freedom of Information Act 1982 is relevant to all government departments, including hospitals and healthcare facilities.
Right to Information Act 2009
and
Information Privacy Act 2009
are examples of Queensland freedom of information legislation.
Details pertaining to Freedom of Information:
8 points
Access to information includes medical records from public sectors (all areas of government), but only access to ‘records’:
written, photos, pictures, drawings, handwritten notes, ‘post its’, diary entries, material held on hard drives, video and audio tapes.
It excludes exhibits, for example alcohol.
Exempt materials are items regarding national security, local security, whistle blowers details, name and addresses of jurors, personal affairs of another.
Blackouts are acceptable in certain situations, for example if the document contains personal affairs of people other than the applicant such as a psychiatric patient and therapeutic privilege.
A document under Freedom of Information cannot be created — only already existing documents can be accessed.
Freedom of Information does not apply to documents that have gone in front of cabinet, regardless of the material. This has on occasion led to an abuse of Freedom of Information legislation and the cabinet (any potentially sensitive material can be presented before a cabinet meeting and then will not be accessible to others).
Queensland Health administers an Access Policy which allows an individual to access material without having to go through Freedom of Information. This might not be true of all public health services, so you need to check the policy of the organisation you are working in.
Always refer enquiries to the person in charge. Any records belong to the healthcare organisation and may not be removed from its premises.
Freedom of Information legislation does not apply to private corporations.
Client access to records in private facilities:
Individual facilities or doctors working in private organisations have no legal responsibility to allow their clients access to their medical records.
In each organisation, there will be a particular way notes are filed, so ask a senior person for advice on how to do this correctly. You might also need to be familiar with some of the terminology used by Medicare as this federal government program provides a source of income for many private medical practices — you might be responsible for lodging claims online or in hard copy.
Complaints:
8 points
All complaints should be taken seriously, regardless of personal feelings/belief/doubt.
Ask the person how they wish to proceed – formally or informally? Sometimes concerns or misunderstandings can be dealt with easily by a manager. Report the concern directly to your supervisor.
Put the person at ease and speak to them in private as they might be nervous or emotional.
Do not take sides but listen impartially to the person. Don’t offer your opinion, for example ‘I cannot believe she did that!’ You might not have all the facts.
Be realistic. Do not tell the person that you can resolve their complaint within a specific timeframe. Rather say that you will pass the information on to your supervisor. Most organisations acknowledge a concern within a specific timeframe, but the resolution timeframe depends on the nature and complexity of the complaint.
Keep all complaints confidential. If they are not kept private, the organisation might manage your performance or conduct.
Accurately document the complaint according to your organisation’s policy and procedure. This can help the person who investigates the concern to make a decision or ask for further information or statements.
Direct or forward the complaint to someone who can suggest a solution or an acceptable action for the client to take. This way the client feels that their complaint has been heard and will be acted upon.
