Medical assisting Administrative and clinical procedures (5e) Chapter 10 Written and electronic documents

After studying this chapter you will be able to: Explain why wellwritten documents are important to the image of the medical practice, describe the types of document supplies that will be used in a medical office, outline the general guidelines to effective writing, list and explain the purpose of different types of documents used in a medical office,...

Written and Electronic Documents

Learning Outcomes (cont.)

10.1 Explain why well-written documents are important to

the 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

Professionalism and Document

Preparation

Learning to

 Create

correspondence properly ensures positive,

effective communication between your office and others.



• Formal business stationary

– Name and address

– Associates

– Phone and fax numbers

– Website information and e-mail

• All professional correspondence

• No 10 – most common size

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 (cont.)

• Identify your reading audience

• Don’t use unnecessary words

• Use active voice

• Use passive voice for negative news

Effective Writing (cont.)

• Be polite and courteous

Match the following:

Apply Your Knowledge

ANSWER:

Nice Work!

Show strong emotionDescribes movementDescribe verbs

According to pronunciationDescribes a person, thing, idea

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

Parts of a Business Letter (cont.)

• Attention line

– Written greeting followed by title and last name

– May use business title or department if name is

not known

Parts of a Business Letter (cont.)

• Body

– Two lines below salutation or subject line

– Single-spaced, two lines between paragraphs

• Complimentary closing

• Signature block

• Identification line

Parts of a Business Letter (cont.)

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.)

paragraphs

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)

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 Concern

B Attention: To Whom It May Concern

C Dear Sir/Madam

D Dear Radiology Department

Apply Your Knowledge

ANSWER:

Written Communication Using Electronic

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

Apply Your Knowledge

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

– Formatting

NEVER skip editing and proofreading steps!

DictionaryMedical Dictionary

Physician’s

Desk Reference

(PDR)

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

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

Apply Your Knowledge

Preparing Outgoing Mail

Preparing Outgoing Mail (cont.)

• Manually folding a letter

Preparing Outgoing Mail (cont.)

• Preparing the envelope

– Use USPS guidelines

– Address placement

– Address format

Apply Your Knowledge

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

U.S Postal Service Delivery

• First-class mail

– 11 ounces or less

– Cost is based on

weight– Forwarded at no extra

cost

• Second class mail

• Media mail

U.S Postal Service Delivery (cont.)

• Parcel Post

• Bound printed material

• Priority mail

• Express mail

U.S Postal Service Delivery (cont.)

U.S Postal Service Delivery (cont.)

Other Delivery Services

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:

B A

Apply Your Knowledge

A First class mail

B Bound printed matter

Processing Incoming Mail

Processing Incoming Mail (cont.)

• Sorting and Opening

– Follow a regular procedure

Processing Incoming Mail (cont.)

• Annotating

– Outline key points

– Write reminders, comments,

or suggestions

• Distributing

• Handling drug and

product samples

Match the following:

Apply Your Knowledge

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

C A B D

C

A B

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,

letter into the envelope Be sure to include any enclosures

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