CHAPTER 10 Written and Electronic Documents 10

CHAPTER 10 Written and Electronic Documents

10 -2 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.

10 -3 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.

10 -4 Introduction • Written documentation – Reflection of the office – Legal documents – Prepare with • Accuracy • Attention to detail

10 -5 Professionalism and Document Preparation Learning to Create Send Receive correspondence properly ensures positive, effective communication between your office and others.

10 -6 Letterhead • Formal business stationary – Name and address – Associates – Phone and fax numbers – Website information and e-mail • All professional correspondence

10 -7 Envelopes • 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

Professionalism and Document Preparation (cont. ) ; Labels Invoices and statements – Preprinted statements – Computer-generated invoices and statements – Superbills or encounter forms 10 -8

10 -9 Apply Your Knowledge 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. 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.

10 -10 Effective Writing • Impression of the physician or office – Appearance – Message • Well written, polite and concise – Letters – Patient instructions – E-mails

10 -11 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

10 -12 Effective Writing (cont. ) • Be polite and courteous • Check – Spelling – Dates and monetary figures • Grammar – no slang • Avoid leaving “widows and orphans”

10 -13 Grammar S ERB V • Excellence is essential and S UN NO PLURALS – Parts of speech – Rules of writing • Templates • Cut, copy, and paste ADJE C TIVE S and ADV E CAPITALIZATION RBS

10 -14 Nice Work! Match the following: Apply Your Knowledge ANSWER: Adjectives Join words or phrases together Interjections Describes nouns and pronouns Possessives Shows ownership Word division Show strong emotion Nouns Describes movement Verbs Adverbs Conjunctions Describe verbs According to pronunciation Describes 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 10 -15

10 -16 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

10 -17 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

10 -18 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

10 -19 Parts of a Business Letter (cont. ) • Notations – May be abbreviated as Encl, Enc, or Encs – Copy notation (c: ) – Number of enclosures and copy recipients

10 -20 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

10 -21 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

10 -22 Letter Styles Letter Style Full-Block Modified. Block Description • Lines are typed flush left • No indented paragraphs • Dateline, complimentary closing, signature block, and notations are aligned at the center of the page or to the right

10 -23 Letter Styles (cont. ) Letter Style Modified. Block with Indented Paragraphs Simplified Description • Paragraphs are indented ½ inch • Modification of full-block style • No salutation, courtesy title, or closing • Subject line in all capital letters • Too informal for medical office

10 -24 Punctuation Styles • Open punctuation uses no punctuation after – The word Attention – The salutation – The complimentary closing – The signature block – The enclosure and copy notations

10 -25 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

10 -26 Interoffice Memorandum (Memo) • Informal written communication within an office INTEROFFICE MEMORANDUM TO: FROM: DATE: SUBJECT:

10 -27 Apply Your Knowledge 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? ANSWER: A. To Whom It May Concern B. Attention: To Whom It May Concern C. Dear Sir/Madam D. Dear Radiology Department

Written Communication Using Electronic Format • Must be grammatically correct • HIPAA applies – Electronic media – E-mail • Not secure • Signed written consent 10 -28

10 -29 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

10 -30 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. Good Job!

10 -31 Editing and Proofreading Editing Proofreading • Check for errors – – – Factual accuracy Logical flow Conciseness Clarity Tone – Grammatical – Spelling – Formatting NEVER skip editing and proofreading steps!

10 -32 Tools for Editing and Proofreading Thesaurus Physician’s Desk Reference (PDR) Dictionary English grammar and usage manual Medical Dictionary Word Processing Spell Checker

10 -33 Editing Process • Language usage – Grammar – Formal • Content – logical thought pattern • Style – appropriate to reader

10 -34 Proofreading • Three types of errors – Formatting – Data – Mechanical

10 -35 Apply Your Knowledge 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.

10 -36 Preparing Outgoing Mail • Signing letters • Using a letter folding and inserting machine – Save time – Different types of folds

10 -37 Preparing Outgoing Mail (cont. ) • Manually folding a letter – Type of envelope • Small • Regular, business • Window – Include enclosures

10 -38 Preparing Outgoing Mail (cont. ) • Preparing the envelope – Use USPS guidelines – Address placement – Address format

10 -39 Apply Your Knowledge How should you prepare envelopes for mailing office correspondence? ANSWER: When preparing envelopes for mailing office correspondence, you should use USPS guidelines. +

10 -40 Mailing Options • Mailing Equipment and Supplies – Letterhead, blank stationery, envelopes – Standard supplies • Forms • Labels • Packaging supplies

10 -41 Mailing Equipment and Supplies • Airmail supplies • Envelopes for overnight delivery services • Postal rates, scales and meters

10 -42 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

10 -43 U. S. Postal Service Delivery (cont. ) • Parcel Post • Bound printed material • Priority mail • Express mail

10 -44 U. S. Postal Service Delivery (cont. ) • Special services – Online postage – Special delivery – Certified mail – Return receipt

10 -45 U. S. Postal Service Delivery (cont. ) • Special services – Registered mail – Delivery confirmation – International mail – Tracing mail

10 -46 Other Delivery Services • Companies – UPS – Fed. Ex – DHL • Messengers or couriers

10 -47 Apply Your Knowledge Which type of mail would you use to send each of the following: ANSWER: Confidential laboratory results C Advertisement about a new service B Patient invoice and billing statements A A. First class mail B. Bound printed matter C. Certified mail D. Express mail 111 One Drive Any, ST 11111 Right!

10 -48 Processing Incoming Mail Steps Recording Sorting and Opening Distributing Annotating

10 -49 Processing Incoming Mail (cont. ) • Sorting and Opening – Follow a regular procedure – Sort by priority • Recording – Daily mail log – Mail received – Follow-up correspondence

10 -50 Processing Incoming Mail (cont. ) • Annotating – Outline key points – Write reminders, comments, or suggestions • Distributing • Handling drug and product samples

10 -51 Apply Your Knowledge Match the following: ANSWER: A. Sorting and Opening B. Recording C. Annotating D. Distributing C A B D C B A 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 CORRECT!

10 -52 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.

10 -53 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.

10 -54 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.

10 -55 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.

10 -56 End of Chapter 10 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