CHAPTER
10
Written and
Electronic
Documents
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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.
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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.
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10-4
Introduction
• Written documentation
– Reflection of the office
– Legal documents
– Prepare with
• Accuracy
• Attention to detail
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10-5
Professionalism and Document
Preparation
Learning to


Create
Send

Receive
correspondence properly ensures positive,
effective communication between your office and
others.
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10-6
Letterhead
• Formal business stationary
– Name and address
– Associates
– Phone and fax numbers
– Website information and e-mail
• All professional correspondence
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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
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10-8
Professionalism and Document
Preparation (cont.)
Labels
 Invoices and statements
– Preprinted statements
– Computer-generated invoices and statements
– Superbills or encounter forms
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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.
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10-10
Effective Writing
• Impression of the physician or office
– Appearance
– Message
• Well written, polite and concise
– Letters
– Patient instructions
– E-mails
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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
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10-12
Effective Writing (cont.)
• Be polite and courteous
• Check
– Spelling
– Dates and monetary figures
• Grammar – no slang
• Avoid leaving “widows and orphans”
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10-13
Grammar
• Excellence is essential
– Parts of speech
– Rules of writing
• Templates
• Cut, copy, and paste
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10-14
Nice
Work!
Apply Your Knowledge
Match the following:
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
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10-15
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
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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
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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
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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
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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
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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
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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
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10-22
Letter Styles
Letter Style
Full-Block
ModifiedBlock
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
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10-23
Letter Styles (cont.)
Letter Style
ModifiedBlock 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
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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
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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
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10-26
Interoffice Memorandum (Memo)
• Informal written
communication
within an office
INTEROFFICE MEMORANDUM
TO:
FROM:
DATE:
SUBJECT:
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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
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10-28
Written Communication Using Electronic
Format
• Must be grammatically correct
• HIPAA applies
– Electronic media
– E-mail
• Not secure
• Signed written consent
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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
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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.
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10-31
Editing and Proofreading
Editing
Proofreading
• Check for
• Check for errors
–
–
–
–
–
Factual accuracy
Logical flow
Conciseness
Clarity
Tone
– Grammatical
– Spelling
– Formatting
NEVER skip editing and proofreading steps!
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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
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10-33
Editing Process
• Language usage
– Grammar
– Formal
• Content – logical thought pattern
• Style – appropriate to reader
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10-34
Proofreading
• Three types of errors
– Formatting
– Data
– Mechanical
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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.
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
10-36
Preparing Outgoing Mail
• Signing letters
• Using a letter folding and inserting
machine
– Save time
– Different types of folds
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
10-37
Preparing Outgoing Mail (cont.)
• Manually folding a letter
– Type of envelope
• Small
• Regular, business
• Window
– Include enclosures
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
10-38
Preparing Outgoing Mail (cont.)
• Preparing the envelope
– Use USPS guidelines
– Address placement
– Address format
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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.
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10-40
Mailing Options
• Mailing Equipment and Supplies
– Letterhead, blank stationery, envelopes
– Standard supplies
• Forms
• Labels
• Packaging supplies
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10-41
Mailing Equipment and Supplies
• Airmail supplies
• Envelopes for overnight
delivery services
• Postal rates, scales and
meters
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
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
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10-43
U.S. Postal Service Delivery (cont.)
• Parcel Post
• Bound printed material
• Priority mail
• Express mail
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10-44
U.S. Postal Service Delivery (cont.)
• Special services
– Online postage
– Special delivery
– Certified mail
– Return receipt
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10-45
U.S. Postal Service Delivery (cont.)
• Special services
– Registered mail
– Delivery confirmation
– International mail
– Tracing mail
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10-46
Other Delivery Services
• Companies
– UPS
– FedEx
– DHL
• Messengers or
couriers
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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!
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10-48
Processing Incoming Mail
Distributing
Annotating
Recording
Sorting and
Opening
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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
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
10-50
Processing Incoming Mail (cont.)
• Annotating
– Outline key points
– Write reminders, comments,
or suggestions
• Distributing
• Handling drug and
product samples
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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
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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.
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
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.
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
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.
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
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.
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
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
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.