Bài dạy Medical Assisting - Chapter 10: Written and Electronic Documents

10Written and Electronic DocumentsLearning 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.IntroductionWritten documentationReflection of the office Legal documentsPrepare withAccuracy Attention to detailProfessionalism and Document PreparationLearning to Create correspondence properly ensures positive, effective communication between your office and others.Send ReceiveLetterheadFormal business stationaryName and addressAssociates Phone and fax numbersWebsite information and e-mailAll professional correspondence No. 10 – most common sizeGrade of paperA less expensive stock and quality for everyday documents A more expensive stock and quality for professional correspondenceEnvelopesProfessionalism and Document Preparation (cont.)Labels Invoices and statementsPreprinted statements Computer-generated invoices and statementsSuperbills or encounter forms1. 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 KnowledgeRight!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 WritingImpression of the physician or officeAppearance Message Well written, polite and conciseLettersPatient instructionsE-mailsEffective Writing (cont.)Identify your reading audience Be conciseDon’t use unnecessary wordsShow clarityUse active voiceUse passive voice for negative newsEffective Writing (cont.)Be polite and courteousCheck Spelling Dates and monetary figuresGrammar – no slangAvoid leaving “widows and orphans”GrammarExcellence is essentialParts of speechRules of writingTemplates Cut, copy, and pasteMatch the following:Apply Your KnowledgeANSWER:Nice Work!AdjectivesInterjections Possessives Word divisionNounsVerbsAdverbsConjunctions Join words or phrases togetherDescribes nouns and pronounsShows ownershipShow strong emotionDescribes movementDescribe verbsAccording to pronunciationDescribes a person, thing, ideaMedical Office Documents and CorrespondenceTypes of correspondenceLetters of referral Letters concerning appointmentsPatient reports for insurance companiesInstructions for examinations or laboratory testsAnswers to insurance or billing questionsCover letters or form lettersParts of a Business LetterLetterheadDateline – 3 lines below letterhead Inside address Includes information needed for correct delivery Two to four spaces below datelineParts of a Business Letter (cont.)Attention line SalutationWritten greeting followed by title and last nameMay use business title or department if name is not knownSubject lineParts of a Business Letter (cont.)Body Two lines below salutation or subject lineSingle-spaced, two lines between paragraphsComplimentary closingSignature blockIdentification lineParts of a Business Letter (cont.)NotationsMay be abbreviated as Encl, Enc, or EncsCopy notation (c:) Number of enclosuresand copy recipientsLetter FormatMargins – one inch for 8 ½-inch wide paperLetter should be centered on the pageSingle-space body of letter and double-space between paragraphsShort sentences with no more than 20 words on an averageLetter Format (cont.)Have at least two or three sentences per paragraphDivide paragraphs longer than 10 lines into shorter paragraphsFor multipage letters, use letterhead for first page onlyLetter StyleDescriptionFull-BlockLines are typed flush leftNo indented paragraphsModified-BlockDateline, complimentary closing, signature block, and notations are aligned at the center of the page or to the rightLetter StylesLetter Styles (cont.)Letter StyleDescriptionModified-Block with Indented Paragraphs Paragraphs are indented ½ inchSimplifiedModification of full-block styleNo salutation, courtesy title, or closingSubject line in all capital lettersToo informal for medical officePunctuation StylesOpen punctuation uses no punctuation after The word AttentionThe salutationThe complimentary closingThe signature blockThe enclosure and copy notationsPunctuation Styles (cont.)Mixed Punctuation includesA colon after Attention A colon after the salutationA comma after the complimentary closingA colon or period after the enclosure notationA colon after the copy notation,::Interoffice Memorandum (Memo)Informal written communication within an officeINTEROFFICE MEMORANDUMTO: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? To Whom It May Concern Attention: To Whom It May Concern Dear Sir/Madam Dear Radiology DepartmentApply Your KnowledgeANSWER:Correct!Written Communication Using Electronic FormatMust be grammatically correctHIPAA applies Electronic mediaE-mailNot secureSigned written consentInteroffice Email Not private Management Check office email regularlyDo not open unidentifiable emailsUse subfolders Set time limits for deleting or retaining messagesSave responses containing PHIApply Your KnowledgeWhy 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 ProofreadingEditingCheck forFactual accuracyLogical flowConcisenessClarityTone ProofreadingCheck for errorsGrammatical SpellingFormattingNEVER skip editing and proofreading steps!DictionaryMedical DictionaryPhysician’s Desk Reference (PDR)English grammar andusage manualWord Processing Spell CheckerTools for Editing and ProofreadingThesaurus Editing ProcessLanguage usageGrammarFormal Content – logical thought patternStyle – appropriate to readerProofreadingThree types of errorsFormattingDataMechanical 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 KnowledgeSpot On!Preparing Outgoing MailSigning lettersUsing a letter folding and inserting machineSave timeDifferent types of foldsPreparing Outgoing Mail (cont.)Manually folding a letterType of envelope SmallRegular, businessWindowInclude enclosures Preparing Outgoing Mail (cont.)Preparing the envelopeUse USPS guidelines Address placementAddress formatApply Your KnowledgeANSWER: When preparing envelopes for mailing office correspondence, you should use USPS guidelines.How should you prepare envelopes for mailing office correspondence?Mailing OptionsMailing Equipment and SuppliesLetterhead, blank stationery, envelopesStandard suppliesFormsLabelsPackaging suppliesMailing Equipment and SuppliesAirmail suppliesEnvelopes for overnight delivery servicesPostal rates, scales and metersU.S. Postal Service DeliveryFirst-class mail11 ounces or lessCost is based on weightForwarded at no extra costSecond class mailMedia mail U.S. Postal Service Delivery (cont.)Parcel PostBound printed materialPriority mailExpress mailU.S. Postal Service Delivery (cont.)Special servicesOnline postageSpecial deliveryCertified mailReturn receiptU.S. Postal Service Delivery (cont.)Special services Registered mailDelivery confirmationInternational mailTracing mail Other Delivery Services Companies UPSFedExDHLMessengers or couriersConfidential laboratory resultsAdvertisement about a new servicePatient invoice and billing statementsWhich type of mail would you use to send each of the following: BAApply Your KnowledgeA. First class mailB. Bound printed matterC. Certified mailD. Express mailANSWER:CRight!111 One DriveAny, ST 11111Processing Incoming MailSorting and Opening RecordingAnnotating Distributing Processing Incoming Mail (cont.)Sorting and Opening Follow a regular procedureSort by priorityRecording Daily mail log Mail receivedFollow-up correspondenceProcessing Incoming Mail (cont.)AnnotatingOutline key points Write reminders, comments, or suggestionsDistributing Handling drug and product samplesMatch the following:Apply Your KnowledgeANSWER: Sorting and OpeningRecordingAnnotatingDistributing 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 systemCABDCABIn Summary10.1 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 LincolnEnd of Chapter 10