elsevier items and derived items 2009 by saunders, an imprint of elsevier inc. chapter 42 written...

Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.

Chapter 42Written Communications

2Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.

Pretest

True or False1. Business letters are more formal than personal

correspondence in form and content.2. The body of a business letter is double spaced.3. The name of the individual sending a business

letter should always be printed below the handwritten signature.

4. If additional forms or printed material is included with a letter, this should be indicated in an end notation.

5. In the semiblock letter style, all lines of the letter are left justified.


Pretest, cont.

True or False6. An adverb modifies a verb, adjective, or other adverb.7. Sentence fragments and comma splices are errors that

should always be corrected in a business letter. 8. A comma should be used to separate two sentences that are

not joined by a conjunction or separated by a period.9. The common headings for a memo are: TO, FROM,

SUBJECT, and DATE.10. Because e-mail and fax transmissions are considered

secure, they are a good way to transmit confidential information about patients.


1. In the past, written communication was usually sent through the mail

2. Today, written communication is also sent electronically

a. Can be viewed or printed after transmissionb. Must adhere to professional standards

3. If written communication contains protected health information, a consent for its release must be obtained from the patient

Introduction to WrittenCommunication


Business Letters

1. Letters must be formatted correctly to maintain a professional imagea. May be dictated by the physician and prepared

by the medical assistant (MA)b. May be composed by the MA

2. Form letters or letters based on templates may be used for routine correspondence


Business Letters, cont.

Equipment and Supplies1. Computer and printer are usually used to

create a letter2. Word processing software facilitates

formatting and corrections3. Letterhead stationery is used with matching

envelopes4. Letters are usually photocopied for the

medical record and if copies are sent to other recipients



Parts of a Business LetterHeading1. Return address is placed at the top of the

letter or letterhead stationery is used2. Date line on second line below return

address or two to three spaces below letterhead

a. Month is written out in fullb. Written as month, day, and year (e.g., January

5, 2009)



Inside Address1. Includes the name and address of the party

to whom the letter is being senta. Located just above the salutationb. Placed on the paper so that the body of the

letter is centered top to bottomc. Inside address is single spaced

2. If the letter will require 2 pages, inside address begins on the second or third line below the date line



Salutation or Greeting1. Formal greeting uses “Dear” plus a title with

the recipient’s surname a. Use of the first name is informal and should be

avoidedb. Not correct to use credentialsc. Example: Dear Dr. Taylor:

2. In a business letter, the salutation is punctuated with a colon

3. Salutation is followed by one blank line



Body of the Letter1. Contains the substance of the letter2. Each paragraph is single spaced with a

double space between paragraphs



Complimentary Close or Closing1. Placed on the second line below the body of

the letter2. First word is capitalized and closing is

followed by a comma3. The standard complimentary close is

“Sincerely” or “Sincerely yours,” 4. More formal closing is “Yours truly,” or “Very

truly yours,”5. Example: “Sincerely yours,”



Signature, Printed Signature, and Title1. Four to five spaces are left after the closing

for the handwritten signature2. The printed signature includes the full name

of the individual sending the letter, including credentials



3. A title may be entered on the line below the printed signature

4. If the MA composes the letter, he or she usually also signs the letter

5. If the physician dictates the letter, the physician will proofread and sign the letter



End Notations1. The order of information given below the

signature may vary according to office policy2. End notations include enclosures, copies,

and initials of the individual who prepared the letter

a. The initials of the individual who dictated the letter are entered in uppercase followed by a slash or colon and the initials of the individual who prepared the letter in lowercase



b. Enclosure(s) may be written out or abbreviated “Enc.”

c. The number of enclosures is given so that the recipient can be sure everything was actually included with the letter

d. The copy notation indicates recipients of copies of the letter. The copy retained by the office is not included in the copy notation



Format of Business LettersSetting up a Letter1. Margins

a. Top margin should accommodate the letterhead

b. Side margins may be 1-2 inchesc. A short letter usually has wider side marginsd. Body of the letter should be centered top to

bottom on the page



2. Fonta. Generally accepted font for business letters is

Times or Times New Romanb. Entire letter (except for letterhead) should be in

the same font3. A header should be placed at the top of a 2-

page letter including recipient, page number, and date



Letter Styles1. Full block style

a. All lines are left justified, but letterhead may be centered

b. Left justified means that the line begins at the left margin

c. A double space is used between the paragraphs of the body of the letter



2. Modified block stylea. All lines in the inside address, salutation, and

body of the letter are left justifiedb. Date line, complimentary close, and printed

signature are right justified or set on a tab at the center or to the right of the center

c. Right justified means ending at the right margin

d. A double space is used between the paragraphs of the body of the letter



3. Semiblock stylea. All lines in the inside address, salutation, and

body of the letter are left justifiedb. Date line, complimentary close, and printed

signature are right justified or set on a tab at the center or to the right of the center

c. All paragraphs are indented and a double space is used between paragraphs



4. Simplified stylea. All parts of the letter (except the letterhead)

must be left justifiedb. The salutation is replaced by a subject line in

all upper case lettersc. The complimentary close is not used, and the

printed signature line is in all uppercase letters five lines below the written signature

d. A double space is used between the paragraphs of the body of the letter



Composing a Business Letter1. Collect information and jot down important

pointsa. Be sure information is in logical orderb. Review old letters for wording

2. Enter the letter into the word processor and format

3. Have a draft letter proofread by the office manager and/or physician if necessary

4. Proofread for accuracy, grammar, and spelling


Responding to WrittenCommunication

1. MA usually responds to correspondence or e-mails related to office management

a. Supply ordersb. Billing or insurance questionsc. Requests for information about the practice


Responding to WrittenCommunication, cont.

2. Correspondence related to patient care is referred to the physician

a. If paper-based medical records are used, MA attaches letter to medical record

b. If physician dictates a reply to a letter related to patient care, MA transcribes the dictation



Grammar and Sentence Structure

1. Grammar is a term meaning the accepted rules to create meaningful sentences

2. MA must always use correct grammar and spelling

3. Parts of speech are categories that describe how words are used



Parts of Speech 1. Nouns

a. A noun is the name of a person, place, or thingb. Common nouns refer to general things or

categoriesc. Proper nouns refer to specific individuals or

places and begin with an uppercase letterd. Examples of common nouns: baseball, rabbit,

medical assistante. Examples of proper nouns: Dean Johnson,

Bugs Bunny, New Orleans



2. Pronounsa. A pronoun is used in place of a nounb. Possessive pronouns show ownershipc. Examples of pronouns: he, she, you, I, themd. Examples of possessive pronouns: mine, his,

their, theirs



3. Verbs

a. A verb either shows action or a state of beingb. A verb that shows a state of being may also

be called a linking verbc. A sentence requires a subject (noun or

pronoun) and a verb to be completed. Examples of action verbs: run, sing, dancee. Examples of verbs that show a state of

being: is, are, seems



4. Adjectives and articlesa. An adjective modifies a nounb. Two or more words used together as one

modifier may be joined by a hyphen (e.g., 20-year-old)

c. English has three articles: a, an, the



5. Adverbsa. An adverb modifies a verb, adjective, or other

adverbb. Words that end in -ly are usually adverbsc. Question words are also adverbs (e.g., who?

where? why?)6. Prepositions

a. A preposition shows the connection of a noun to some other word

b. Prepositions often show relationships of space, time, or possession

c. Examples of prepositions: to, on, above, of, in



7. Conjunctionsa. A conjunction joins words, phrases, or clauses

in a sentenceb. Examples of conjunctions: and, but, or,

because8. Interjections

a. An interjection is a word that expresses feelings

b. Examples of interjections: oh! yeah! ouch!



Sentence Structure1. Simple sentence

a. A simple sentence is composed of one independent clause

b. Example: The dog was very hungry.2. Compound sentence

a. A compound sentence is composed of two independent clauses

b. A comma separates the two independent clauses in a compound sentence

c. Example: The dog returned from its walk, and it drank all the water in its bowl.



3. Complex sentencea. A complex sentence consists of one independent

clause and one or more dependent clausesb. A dependent clause cannot stand alone c. If a dependent clause begins a sentence, it is

followed by a commad. If a dependent clause follows an independent

clause, a comma is not usede. Examples:

• When it returned from its walk, the dog drank all the water in its bowl.

• The dog drank all the water in its bowl when it returned from its walk.



Sentence Errors1. Sentence fragment

a. A dependent clause is used to stand alone as a sentence

b. An additional independent clause is necessary for meaning

c. Example: When I arrive for my appointment.



2. Run-on sentencea. It is a sentence in which two or more

independent clauses are used without a conjunction

b. My appointment is on Thursday I will bring my insurance card.

3. Comma splicea. It is the incorrect use of a comma to separate

two sentencesb. Example: My appointment is on Thursday, I will

bring my appointment card.



When to Use a Comma1. To separate the elements in a series of

three or more thingsa. Example: The patient complained of abdominal

pain, difficulty breathing, and headache.2. Before a conjunction that joins an

independent clausea. Example: The patient called an ambulance,

and the ambulance brought her to Memorial Hospital.



3. To set off introductory elements like prepositional phrases or dependent clausesa. Example: After the upper GI, the patient

continued to experience abdominal pain.4. To set off information that could be omitted

or placed in parentheses without changing the meaning of the sentencea. Example: The patient, who was referred by Dr.

Johnson, had an appointment today.



5. Before quotations marks that open a quotationa. Example: The patient said, “My incision burns

like fire.”6. To avoid confusion

a. Example: For most, the academic year is already finished.



7. Between the city and state, the day of the month and the year, a name and the titlea. Example: June 17, 1987 BUT June 1987

8. With terms like not, however, and but to express contrasta. Example: The wound was large, but it was

healing well.



9. To separate appositives, nouns of direct address, titles that follow a person’s name, and introductory words from the rest of the sentencea. Example: We will make an appointment with

Dr. Cannon, a gynecologist.10. To separate parenthetical expressions

from the rest of the sentencea. Example: The report, I hope, will give you

more specific information.



Spelling

1. Proofread all documents for spelling2. Spell check is helpful but cannot verify that

a word is correct in context3. Keep a list of difficult words and try to learn

them4. A medical dictionary and computer program

can be helpful


Transcription

1. Purpose of transcription is to change dictated notes into a printed format

2. Most physicians either dictate notes or use an electronic medical record

3. Dictated files are usually transferred from a hand-held machine to a computer


Transcription, cont.

4. Transcription is done using headphones and a foot pedal to start and stop the dictation

5. Voice recognition system can transcribe automatically, but the transcription must be edited

6. Transcription is often done by a transcription service with the returned files printed in the office



Letters1. Letters should be transcribed using one of

the standard letter formats2. Use a reference line with the initials of the

physician who dictated the letter in uppercase followed by the MA’s initials in lowercase

3. Make any needed changes after the letter has been corrected by the physician

4. Obtain the physician’s signature before mailing



Memoranda

1. A memo is used to communicate within a business

2. Memo headings include the names of the individuals to whom it is sent, the name of the person sending the memo, the date, and the subject

3. The message is informative and succinct4. The memo may be sent in hard copy or as

an attachment to an e-mail



Medical ReportsProgress Notes1. Progress notes may be set up in SOAP

format or using other headings2. Include the patient’s name, date of birth, and

date of the office visit3. Single space with two spaces between

paragraphs or headings



4. Entries under Assessment and Plan are usually numbered

5. Leave a space for the physician to sign the note

6. Print note on separate piece of paper or paper with adhesive backing to mount

7. The physician may incorporate vital signs done by the MA into the progress note



History and Physical Examination Reports1. Use the format preferred by the medical

office2. Sections usually include identifying

information, sections of the history, and sections of the physical examination



3. The text of each section may be left justified or indented

4. There is usually a separate section for each body system examined

5. The final sections include the impression (assessment or diagnosis) and plan for treatment



Consultation Reports1. May be dictated as a letter or in a format

similar to the physical examination2. Physicians in a specialty send consultation

reports to the referring physician



Proofreading1. Look up any unfamiliar words to verify

spelling2. Write out abbreviations for medical

conditions, but use standard abbreviations for medication times, measurements, and vital signs



3. Personalize the spell check program by adding commonly used words

4. Leave a space if there was an unintelligible word so that the physician can fill it in before signing


Electronic Data Transmission

E-Mail

1. A method of exchanging information between individuals using a computera. Usually uses a format like a letter, but less

formalb. Usually not used with patientsc. Should contain a subject lined. Use correct grammar and spelling

2. Subsequent e-mails usually created as a reply so that previous communication is included


Electronic Data Transmission, cont.

3. Abbreviations, humor, and negative comments should be avoided in e-mails to business contacts

4. Assume that e-mails are not private and do not include confidential information

5. Be sure that e-mails are sent to the correct recipient

6. Print e-mails that contain information related to orders or other business transactions



E-mail Attachments1. Documents, images, and other types of files

can be sent as attachments2. Attachments may transmit viruses, so open

them only if from a trusted source3. Attachment must be opened with a

compatible programa. Save documents as text file if you do not use a

standard word processing programb. Files can also usually be saved as web pages



Fax Transmissions

1. Fax is sent with a cover sheet to identify the sender

a. Medical office usually uses a confidentiality statement on the fax cover sheet

b. Cover sheet often printed on office letterhead2. Fax transmissions are not considered

secure and should be avoided for patient information unless there is a need for rapid transmission of information


Photocopying

1. Learn how to use the features of the photocopy machine

a. Remove staples and arrange documents before copying

b. Most machines will collate pages (arrange in order) and staple

c. If collating manually, pay attention to retain correct order of pages

d. Many machines will produce two-sided copies


Photocopying, cont.

2. Be sure patient has signed a release before copying patient information

3. After copying be sure no originals are left at the machine

4. Shred any spoiled copies containing patient information


Posttest

1. All business letters sent from the medical office are dictated by the physician and prepared by office staff.

2. The inside address of a business letter is placed two lines below the date line.

3. The standard closing of a business letter is “Sincerely yours.”

4. If a letter has been dictated by the physician and prepared by the medical assistant, a reference line should be included below the typed signature.

5. In the modified block letter style, the date line, complimentary close and printed signature may be lined up at the center of the letter.

True or False


Posttest, cont.

6. A conjunction joins words, phrases, or clauses in a sentence.

7. When two sentences are connected without punctuation, it is called a comma splice.

8. A comma should be used to set off information that could be omitted from a sentence without changing the meaning.

9. Progress notes dictated by a physician are often set up in SOAP format.

10. Most office photocopy machines will collate and staple documents, as well as copy on both sides of a piece of paper.

True or False