Written and Electronic Documents

transcript

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CHAPTER

10Written and Electronic

Documents

Learning Outcomes (cont.)

10.1 Explain why well-written documents are important tothe image of the medical practice.

10.2 Describe the types of document supplies that will be used in a medical office.

10.3 Outline the general guidelines to effective writing.

10.4 List and explain the purpose of different types of documents used in a medical office.

10.5 Explain why it is important to have a signed written consent from the patient for e-mail communications.

Learning Outcomes (cont.)

10.6 Describe the tasks involved in editing and proofreading a document.

10.7 Outline the steps for preparing a completed letter for mailing.

10.8 Explain the differences among the different types of mail services offered by the USPS.

10.9 Describe the steps involved in processing incoming mail.

Introduction

• Written documentation

– Reflection of the office

– Legal documents

– Prepare with

• Accuracy

• Attention to detail

Professionalism and Document Preparation

Learning to

Create

correspondence properly ensures positive, effective communication between your office and others.

Send Receive

Letterhead

• Formal business stationary– Name and address– Associates – Phone and fax numbers– Website information and e-mail

• All professional correspondence

• No. 10 – most common size

• Grade of paper– A less expensive stock and quality for

everyday documents

– A more expensive stock and quality for professional correspondence

Envelopes

Professionalism and Document Preparation (cont.)

Labels

Invoices and statements

– Preprinted statements

– Computer-generated invoices and statements

– Superbills or encounter forms

1. How does the quality of writing materials reflect back on a medical practice?

ANSWER: Quality of writing materials conveys a professional image that reflects on the entire office staff.

Apply Your Knowledge

2. When sending correspondence to another physician’s office, the medical assistant used the first envelope he came across. It was an envelope used for invoices and he put the address label over the window. What should he have done?

ANSWER: The medical assistant should have looked for an envelope that matched the letterhead paper used.

Effective Writing

• Impression of the physician or office– Appearance

– Message

• Well written, polite and concise

– Letters

– Patient instructions

– E-mails

Effective Writing (cont.)

• Identify your reading audience

• Be concise

• Don’t use unnecessary words

• Show clarity

• Use active voice

• Use passive voice for negative news

Effective Writing (cont.)

• Be polite and courteous

• Check – Spelling – Dates and monetary figures

• Grammar – no slang

• Avoid leaving “widows and orphans”

Grammar

• Excellence is essential

– Parts of speech

– Rules of writing

• Templates

• Cut, copy, and paste

Match the following:

Apply Your KnowledgeANSWER:

Nice Work!

Adjectives

Interjections

Possessives

Word division

Adverbs

Conjunctions

Join words or phrases together

Describes nouns and

pronouns

Shows ownership

Show strong emotion

Describes movement

Describe verbs

According to pronunciation

Describes a person, thing,

Medical Office Documents and Correspondence

• Types of correspondence

– Letters of referral

– Letters concerning appointments

– Patient reports for insurance companies

– Instructions for examinations or laboratory tests

– Answers to insurance or billing questions

– Cover letters or form letters

Parts of a Business Letter

• Letterhead

• Dateline – 3 lines below letterhead

• Inside address – Includes information needed for correct

delivery – Two to four spaces below dateline

Parts of a Business Letter (cont.)

• Attention line

• Salutation– Written greeting followed by title and last

name– May use business title or department if name

is not known

• Subject line

• Body – Two lines below salutation or subject line– Single-spaced, two lines between paragraphs

• Complimentary closing

• Signature block

• Identification line

• Notations

– May be abbreviated as Encl, Enc, or Encs

– Copy notation (c:)

– Number of enclosuresand copy recipients

Letter Format Margins – one inch for 8 ½-inch wide paper

Letter should be centered on the page

Single-space body of letter and double-space between paragraphs

Short sentences with no more than 20 words on an average

Letter Format (cont.)

Have at least two or three sentences per paragraph

Divide paragraphs longer than 10 lines into shorter paragraphs

For multipage letters, use letterhead for first page only

Letter Style Description

Full-Block • Lines are typed flush left• No indented paragraphs

Modified-Block

• Dateline, complimentary closing, signature block, and notations are aligned at the center of the page or to the right

Letter Styles

Letter Styles (cont.)

Letter Style Description

Modified-Block with Indented Paragraphs

• Paragraphs are indented ½ inch

Simplified • Modification of full-block style• No salutation, courtesy title, or

closing• Subject line in all capital letters• Too informal for medical office

Punctuation Styles

• Open punctuation uses no punctuation after – The word Attention

– The salutation

– The complimentary closing

– The signature block

– The enclosure and copy notations

Punctuation Styles (cont.)

• Mixed Punctuation includes– A colon after Attention

– A colon after the salutation

– A comma after the complimentary closing

– A colon or period after the enclosure notation

– A colon after the copy notation

Interoffice Memorandum (Memo)

• Informal written communication within an office

INTEROFFICE MEMORANDUM

TO:FROM:DATE:

SUBJECT:

What should the medical assistant do if a mailing is to be sent to an organization to request x-ray films, but no specific name or title is given to address it to? Which of the following would you use?

A. To Whom It May ConcernB. Attention: To Whom It May ConcernC. Dear Sir/MadamD. Dear Radiology Department

ANSWER:

Written Communication Using Electronic Format

• Must be grammatically correct

• HIPAA applies

– Electronic media

– E-mail• Not secure• Signed written consent

Interoffice Email

• Not private

• Management

– Check office email regularly

– Do not open unidentifiable emails

– Use subfolders

– Set time limits for deleting or retaining messages

– Save responses containing PHI

Why is it important to have a signed consent for email communication from a patient?

ANSWER: HIPAA law applies to email communication. Since emailing is not a secure form of communication, PHI could be intercepted by someone other than the intended recipient.

Editing and Proofreading

Editing• Check for

– Factual accuracy– Logical flow– Conciseness– Clarity– Tone

Proofreading• Check for errors

– Grammatical – Spelling– Formatting

NEVER skip editing and proofreading steps!

Dictionary

Medical Dictionary

Physician’s Desk Reference

English grammar andusage manual

Word Processing Spell Checker

Tools for Editing and Proofreading

Thesaurus

Editing Process

• Language usage

– Grammar

– Formal

• Content – logical thought pattern

• Style – appropriate to reader

Proofreading

• Three types of errors

– Formatting

– Data

– Mechanical

What is the difference between editing and proofreading ?

ANSWER: Editing is the process of checking a document for factual accuracy, logical flow, conciseness, clarity, and tone. Proofreading is the process of checking a document for grammatical, spelling, and formatting errors.

Preparing Outgoing Mail

• Signing letters

• Using a letter folding and inserting machine

– Save time

– Different types of folds

Preparing Outgoing Mail (cont.)

• Manually folding a letter

– Type of envelope

• Small

• Regular, business

• Window

– Include enclosures

Preparing Outgoing Mail (cont.)

• Preparing the envelope

– Use USPS guidelines

– Address placement

– Address format

ANSWER: When preparing envelopes for mailing office correspondence, you should use USPS guidelines.

How should you prepare envelopes for mailing office correspondence?

Mailing Options

• Mailing Equipment and Supplies– Letterhead, blank stationery, envelopes

– Standard supplies• Forms• Labels• Packaging supplies

Mailing Equipment and Supplies

• Airmail supplies

• Envelopes for overnight delivery services

• Postal rates, scales and meters

U.S. Postal Service Delivery

• First-class mail– 11 ounces or less– Cost is based on

weight– Forwarded at no extra

• Second class mail

• Media mail

U.S. Postal Service Delivery (cont.)

• Parcel Post

• Bound printed material

• Priority mail

• Express mail

• Special services

– Online postage

– Special delivery

– Certified mail

– Return receipt

• Special services

– Registered mail

– Delivery confirmation

– International mail

– Tracing mail

Other Delivery Services

• Companies

– UPS

– FedEx

– DHL

• Messengers or couriers

Confidential laboratory results

Advertisement about a new service

Patient invoice and billing statements

Which type of mail would you use to send each of the following:

A. First class mailB. Bound printed matterC. Certified mailD. Express mail

ANSWER:

Right!

111 One Drive

Any, ST 11111

Processing Incoming Mail

Sorting and Opening

Recording

Annotating

Distributing

Processing Incoming Mail (cont.)

• Sorting and Opening

– Follow a regular procedure

– Sort by priority

• Recording

– Daily mail log

– Mail received

– Follow-up correspondence

Processing Incoming Mail (cont.)

• Annotating

– Outline key points

– Write reminders, comments, or suggestions

• Distributing

• Handling drug and product samples

Match the following:

ANSWER: A.Sorting and OpeningB.RecordingC.AnnotatingD.Distributing

highlighting key points follow a regular procedure keep a log place in a folder with highest priority items on top attaching prior correspondence to a letter indicate follow-up and date it is completed use a priority system

In Summary

10.1 Well-written, neatly prepared documents are one of the most important means of communicating a professional image for the medical practice.

10.2 Document supplies used in a medical office include: letterhead and matching plain bond paper; matching envelopes for professional correspondence; lesser bond envelopes of varying sizes for other types of correspondence; padded envelopes and data

mailers; and labels and statements.

In Summary (cont.)

10.3 Know the type of person to whom you are writing and the purpose of the letter. Use clarity. Check spelling, grammar, and accuracy.

10.4 A medical office uses different types of documents and correspondence. Also, internal documents like memos may be used to provide staff information.

10.5 All patient information, regardless of the form, is protected by HIPAA law and is to be guarded by the healthcare provider. Before undertaking email

communication with a patient, a signed written consent for email communication must be on file.

In Summary (cont.)

10.6 Editing involves checking a document for factual accuracy, logical flow, conciseness, clarity, and tone. Proofreading involves checking a document for grammatical, spelling, and formatting errors.

10.7 After you have created, edited, and proofread a letter, it must be prepared for mailing. This preparation includes having the letter signed,

preparing the envelope, and folding and inserting the letter into the envelope. Be sure to include any enclosures noted in the letter when folding it for insertion into the envelope.

In Summary (cont.)

10.8 The mail delivery options offered by the USPS include: special delivery, certified mail, return receipt requested, registered mail, and delivery confirmation.

10.9 The steps involved in processing incoming mail include: sorting and opening, recording, annotating, and distributing.

If a fellow wants to be a nobody in the business world, let him neglect sending the mailman to somebody on his behalf.

—Abraham Lincoln

End of Chapter 10