chapter 5 (MED184)

When an assistant realizes that a message will have to be taken, a complete message will contain at least nine essential pieces of information necessary to process the message (Procedure 5.2):

1. Date and time of call. On every message, list the complete date (month, day, and year) that the call came in. AM or PM should be identified with the time. The date and time of a message are vital pieces of information should a question or problem later arise involving the patient's care. When a message is recorded in an EHR, the system will automatically enter the date and time on the message. 2. Caller's name. The caller's complete name should be obtained. In the case of a parent who is calling on behalf of a child, the call will be returned to the parent, but the medical staff will need the child's medical record when speaking with the parent. 3. Patient's name. In an EHR, the system will enter the patient's name automatically when the patient's name is selected in the message field. 4. Medical record number or unique identifier. If the call involves anything regarding the patient's health or medical history, the patient's medical information will be needed. The physician may have to review the patient's past medical history and/or medications and will need to make a notation in the record regarding the disposition of the call. The message should include either the patient's health record number or date of birth, either of which is unique to the patient. To accurately identify the patient's record, obtain the patient's date of birth. If a patient calls with a medical question and is a new patient to the practice, obtain the patient's date of birth to see whether information may have been received about the patient. It then should be noted on the message that the patient is new or does not have medical information on file with the practice. 5. Provider name or the person who is called. This identifies the individual to whom the call is directed, such as physician, nurse, therapist, etc. 6. Operator (person receiving the call—assistant's name or initials). The assistant who is taking a message must sign each message. This is done because if the medical staff has a question about the message, they may need to talk with the assistant who took the message. In most offices, the operator may be identified by his or her initials. 7. Message narrative. Information given to the assistant in the conversation with the patient should be listed on the message. This includes the patient's concern or reason for calling the medical office. The assistant also should include the action requested by the caller. Often, options for action are listed on the message form. A box to check in front of items such as "please return call" or "urgent" may be included on the message form. The assistant also may have to write a patient's request for action in the message narrative. An example of an action would be a request that a prescription be filled at a particular pharmacy. 8. Telephone number. A telephone number at which the caller can be reached should be obtained for each message. If the caller will be available only at a certain time, note the availability near the telephone number (e.g., "555-1122 after 3 PM"). Some callers may want to leave more than one number, such as a cell number or a work number. Because many people have cell phones from an area of the country in which they don't live, area codes should be included with all telephone numbers to ensure that the patient will be able to be reached.

Block style

A block-style letter is probably the easiest type of business letter to produce. All letter components are flush with the left margin of the page. No indentations are used in this style, with the exception of tables or other elements that may have to be set apart in the body of the letter. An example of the block style, also known as full-block style, is shown in Fig. 5.6.

Proper Format

A business letter can be formatted properly in various ways. Some of the more commonly used formats are the block style (see Fig. 5.6) and the modified-block style (see Figs. 5.7 and 5.8). Most letters begin 2 inches from the top of the page. This spacing allows room for any letterhead that may be used. Occasionally, a letter may be lengthy, and you may have to alter the top and bottom margins to fit the letter on one page. Be sure to leave enough room at the top and bottom of the page to create a professional-looking letter. Spacing for the various components of a letter is shown in Figs. 5.6, 5.7, and 5.8. Top and bottom margins should be set at 1 inch. Depending on the type of word processing used, default settings for side margins may range from 1 to 1.25 inches. Margins can be adjusted for both short and long letters to make the letters look more appealing on the page. You may wish to change default settings for margins to accommodate an office's letterhead.

Closing

A complimentary closing such as Sincerely or Cordially is used to end the letter. Then the author's name is typewritten on the fourth line below the closing. This produces a blank space of three lines in which the author can sign the letter. Letters authored by physicians are signed with the use of MD and any other academic notations after the physician's name, for example, Dr. Timothy I. Marks, MD, PhD, or Dr. Kristine O'Brian, MD.

Facsimile and digital devices

A facsimile, or fax, machine is a valuable piece of equipment in the medical office. Fax machines allow printed data to be transmitted almost instantly to another location anywhere in the world. A document is read electronically by one fax machine at one location and is transmitted to a fax machine at another location. Anything that is readable on a sheet of paper can be faxed; however, faxing is not the usual way to send medical information. Faxing is done only when the information must be transmitted expediently for care of the patient. When transmitting medical information by fax, an assistant must exercise great care in entering the fax number. If one number is entered incorrectly, sensitive information may end up in the wrong hands. New technology enables documents to be electronically sent using a device called a digital sender. Such equipment can scan many pages quickly and convert the pages into a pdf document. The machine then can be used to email the pdf file to any email address. Information from an EHR can also be converted to a pdf format and sent electronically. Using such equipment has the same HIPAA privacy concerns as previously mentioned for mobile devices. It is critical to ensure that the information is going only where it needs to go. A patient's medical information should not be sent without the patient's expressed consent. In the case of an emergency or life-threatening situation, material may be sent without the patient's knowledge if the information is needed to treat the patient; however, such a release of information occurs infrequently and is approved by the health care provider.

Developing a Personal Directory

A personal directory of frequently called numbers should be kept on hand at the front desk. It is the responsibility of the front desk staff to maintain a directory of telephone numbers for physicians and other staff members, as well as for other businesses that are frequently contacted by the office. These numbers should be recorded in an easy-to-use reference, such as a computer list or a printed paper file. The directories then should be available at the front desk and at other office telephones to allow easy accessibility for all office staff. An Internet search is often used to locate contact information for other health care providers or facilities. Frequently called numbers also can be stored in memory on many telephones. This storage can substantially reduce the amount of time it takes to dial a frequently called number. If the practice is continually calling another location, such as another physician's office, a laboratory, a hospital, or a surgery center, storing these numbers in the telephone's memory can save a lot of time.

After-hours calls

A practice will have patients who call when the clinic has closed. A practice must make arrangements to respond to after-hours calls. Answering services and voicemail systems are effective tools for handling after-hours calls. The use of one of these methods is essential in helping the medical office communicate with patients regarding what they should do if they need medical attention and the office is closed. Even though the office has voicemail or an answering service, an assistant should not rely on these alternatives to answer the telephone during business hours.

Voicemail

A voicemail service is usually purchased along with standard telephone service. Voicemail plays a recorded message from the medical office staff when the telephone line is not answered after a certain number of rings. Voicemail can allow incoming messages to be recorded when the line is not answered or when a line is busy. Messages then may be played back when the assistant accesses the voicemail system. With today's technology, incoming calls are now tracked with computer programs, and these programs can store messages from patients and have the capability to recall messages almost instantly. Some offices may prefer to not allow messages to be recorded during or after hours. If a patient would call with a serious medical situation, an office may prefer to not have the patient leave a message as patients expect a return call if they are able to leave a message. If a patient calls after hours, an outgoing message should be recorded that instructs the patient as to what should be done to get needed medical treatment until the office opens again. A message similar to the following might be used: You have reached Walden-Martin Family Medical Clinic. Our office is now closed. If you are calling about a medical emergency, please hang up and call 911. If you need immediate medical attention for a reason other than an emergency, 24-hour urgent care services are available at our facility located at 1234 Anystreet, Anytown. Our regular office hours are 9 AM to 6 PM weekdays and 9 AM to 12 PM on Saturday. Thank you for calling.

Closing the call

After action on the call has been confirmed, ask the caller if there is anything else that the caller needs. If not, you should say goodbye with an appropriate closing. Possible closings include the following: • "Thank you for calling." • "I'll take care of this right away." • "Have a nice day." • "Thank you."

Identification of the operator and an offer of help

After identifying the facility or department, the operator states his or her name. The operator is the individual who answers the call. In smaller facilities, very often the operator is the assistant who takes the call and performs tasks necessary to complete the handling of the call. If a patient leaves a message, schedules an appointment, or makes another request, it is likely that the assistant will directly help the patient. The assistant's name is given so the patient will be able to identify the individual who provided assistance if future questions regarding the patient's call should arise. Larger facilities that handle a tremendous volume of calls usually have a central switchboard setup in which one or more individuals answer incoming calls. In this type of health care facility, incoming calls usually are answered with a welcome, identification of the facility, and an offer of assistance. The switchboard operator does not give his or her name because the operator does not directly deal with the call other than to transfer the call to someone who will assist the patient. A greeting such as "Good afternoon, Walden-Martin Family Medical Clinic" or "How may I direct your call?" would be appropriate, although a facility may prefer that the operator be identified to add a personal touch to the conversation.

Action

After the assistant has determined why the caller is calling and who the caller is, it is time to take action. At this point, the assistant decides what needs to be done (transfer the call or assist the patient directly), and that action is then taken. Be sure to give the patient enough time to relay all concerns. Occasionally, an assistant may not be able to complete the patient's request right away, but instead may have to handle a patient's request later in the day (as in the case of release of medical records to another facility), when the business of the office has slowed down.

Outgoing Calls

Although many of the practice's calls will be incoming calls, occasionally an assistant will have to call a patient. Patient contact information should be readily available in the practice's patient database. When the patient has an encounter with the health care facility, it is customary to verify the patient's address and phone number just to be sure that the database is correct.

Answering services

An answering service is an outside company that provides individuals who answer the office telephone (at an offsite location) when the practice is closed. This alternative is used by practices that prefer to not have a machine or a recording answer the telephone. An answering service answers the telephone during off hours and may give specific instructions to a patient regarding after-hours care or may relay a message from a patient to an on-call provider. Answering services charge a monthly fee for services rendered. Large group practices may prefer to provide their own staff to answer after-hours calls. Clinics, hospitals, and even insurance companies may decide to employ nursing staff who answer help lines 24 hours a day. Patients who fall ill or are injured after hours can call in and ask the nursing staff questions regarding their health situation. The staff in turn helps determine whether the patient needs immediate medical treatment.

Email

An electronic mail message, or email, is a quick, efficient way to communicate internally in the office. Almost instantly, a printed message can be sent virtually anywhere. Email can be sent to one individual or to a group of individuals. Email can be used to communicate information internally, just as a memo is used. Because it is so easy to use, email is sometimes overused. You should be careful not to email anything unless it is necessary. Because of the volume of email that some offices produce, it is not unusual for someone to be gone from the office for a couple of days and come back to find 50 or even 100 email messages. Reading unnecessary emails uses up valuable employee time that would be better spent assisting patients.

Summary

As a medical administrative assistant, you will interact with patients and others every day in one way or another. It is absolutely critical that you use the proper communication skills and techniques to ensure a more effective and smooth-running office. The telephone is the central communication tool used between office staff members and patients, and professional telephone communication skills must be used by staff members to maintain the professional image of the medical office. A consistent telephone protocol will ensure that calls are handled in a professional and appropriate manner. Because the telephone is the key piece of equipment used by patients when contacting the medical office, attention must be paid to how callers are screened, asked to hold, assisted, and transferred. A variety of telephone communications equipment can be used in providing professional service to patients. Technology is changing the way patients communicate with the office. With the use of patient portals, the computer is an important communication link between the patient and the office. Occasionally, the office needs to communicate with a patient in writing. It is normally the medical administrative assistant's responsibility to prepare a letter to a patient. Proper grammar and document formatting skills must be used when business correspondence is produced. A medical office sends and receives correspondence each day that must be processed internally within the office before it is filed in a patient's chart or picked up for delivery. Whether conversing with a patient in person, on the telephone, or via written correspondence, an assistant must be professional at all times and should strive to meet the patient's needs whenever possible. Professional customer-oriented communication is the foundation of a long-lasting relationship between the patient and the medical office.

Reason for the patient's call

As mentioned previously, every call is answered with a greeting. After the greeting has been extended, the most important piece of information needed by the medical administrative assistant is the reason the caller has called the office. In almost every other type of business, typical telephone practice is to identify the caller first. That is not the case in the medical office. Because you will be working in a medical office, the reason for the call may be a medical emergency. If a patient is calling with an emergency situation, the call must be handled quickly because seconds may make a difference. Identification of common emergency calls is addressed later in this chapter.

Telephone Protocol

Because many different types of situations can arise in the medical office, an established telephone protocol gives the medical administrative assistant a guide to follow when processing incoming calls. Protocol refers to instructions that should be used in response to a particular event. An established protocol gives an individual a guide to use when responding to a situation. Each office should establish a specific telephone protocol to be used in handling calls that come into the office. An example of a telephone protocol given in Table 5.1provides a sample of the numerous types of calls that come into a practice and a possible response for each call. Table 5.1 is not a definitive list of calls, and before a telephone protocol is put into use in any practice, it must be reviewed and approved by the practice physician or physicians.

Telephone screening

Because of the large volume of telephone traffic that most medical offices experience, screening of incoming calls is an absolute necessity in the medical office. The screening process involves obtaining enough information about the call to handle it at the front desk or to transfer the call to the proper department. Screening actually reduces the number of calls that go back to the physician or nurse. If someone else in the office can handle a call, this makes the physician's time more productive. If at all possible, calls should be handled by the front desk. Many patients will call a medical office and ask to speak to the physician directly. It is not often that such a call is transferred directly to the physician. Nearly all physicians prefer to have a message taken and then to have the message attached to the patient's medical record. The message and record then are forwarded to the physician. Physicians must refer to the patient's medical record so they can become familiar with the fine points of the patient's medical history and can document any call regarding medical treatment or advice given to the patient.

Cell phones and mobile devices

Cell phones, too, can help the physician stay in touch with the office when the physician is away. Cell phones allow physicians to stay in immediate contact with the practice. A major concern with cell phones and mobile devices such as tablets is data security. It is important for an office to develop a mobile device policy that addresses how these devices may be used when confidential medical information is accessed or discussed. There are a multitude of potential security risks with personal or organization-owned cell devices that are in use in a health care facility. Is any protected health information shared via phone? What data could be stored on a phone? What if a cell phone is lost or stolen? What apps are installed on the phone? What if a virus or malware is downloaded on the phone? Is the user accessing data using secure networks? Should others be allowed to use the device? These are just a few of the many potential issues that could cause a serious data breach. When cell phones or other mobile devices are used, specific guidelines must be in place to protect patients and the health care facility from any HIPAA violations. According to https://www.HealthIT.gov, there are basic safeguards for protecting patient's personal health information. • Set strong passwords. • Use encryption. • Use automatic log off. • Require a unique user ID. • Enable remote wipe (in case device is lost or stolen). • Lock device. • Keep the device with you. • Use a screen shield. • Refrain from sharing the device (even with friends or family). • Register the mobile device with your health care organization. • Install a firewall. • Use a secure Wi-Fi connection. • Research apps before downloading. It is vitally important for all health care staff to be aware of all policies that pertain to using mobile devices in a health care facility. Recognizing potential areas for security breaches will enable staff to keep patient's protected health information secure.

Nonverbal Communication

Communication does not have to be a spoken or written message. Communication can occur without anyone speaking or writing anything. This type of communication is nonverbal communication and is more commonly known as body language. Nonverbal communication, or body language, is a sign or signal given by the body. These visual clues may have a greater impact on the conversation than words that are spoken. Take a look at the interactions pictured in Fig. 5.1. One of the interactions is much friendlier appearing than the other. Note how each individual in each situation is sending a strong nonverbal message with eyes, arms, and other parts of the body. An individual's appearance and body language can communicate interest or disinterest to another individual. Individuals transmit and receive many body signals subconsciously. We may not know what gives us a certain feeling about a person, but we often get that feeling from the body signals that are being sent. A frown, slumping posture, or eyes that wander create a negative image and demonstrate disinterest toward another individual. A smile or a friendly nod creates a pleasant encounter.

Email Etiquette

Email users must always use proper email etiquette when writing messages. Proper etiquette for business use of email includes the following: 1. Avoid using solid capital letters (e.g., "THIS NEEDS TO BE DONE IMMEDIATELY") or do so with extreme caution. The use of solid capital letters is equivalent to shouting at the other person. 2. It has become common practice to use all lowercase letters for casual, informal email conversations. In informal messages, everything, including the beginning of sentences, may be typed in lowercase letters. This practice, however, is not suitable for business communication in the medical office. In communicating with patients, appropriate business grammar should be used. 3. Be brief but as precise as possible. Oftentimes miscommunication may occur because each individual may react differently to the same statement. Remember, as the message is read, the sender of the statement has no opportunity to see the reaction of the receiver. 4. The use of symbols to convey feeling or emotion, sometimes known as emoticons, may help bridge a possible communication gap. For example, a colon and right parenthesis —:) — signifies the sender's happiness during communication. 5. Texting language is not suitable for business email. Use of such abbreviations is more casual than business-like and should be avoided in office communication. 6. Above all, avoid discussing sensitive issues or serious subjects via email. The likelihood that the message will be misunderstood is great, and a more personal form of communication (in person or a telephone call) should be used to avoid misunderstanding.

Communication Within the Health Care Team

Every medical administrative assistant will have to work with someone during the course of employment; an assistant may work alongside someone all the time or may have only periodic interactions with coworkers. In large offices, several medical administrative assistants may be employed. These individuals need to develop a close working relationship with one another. It is important for coworkers to treat one another with respect and courtesy. Some conflicts in the office may start because of one person's feeling of superiority or indifference to others. All members of the health care team must develop a good working relationship with one another, be tolerant of differences in others, and remember that all members of the health care team are important. When communicating with physicians and other providers in the office, it is important for an assistant to realize that physicians and other providers (e.g., nurse practitioners, nurse midwives, physician assistants, therapists) have a tremendous responsibility in providing health care treatment, and their activities are chiefly responsible for generating the income of the practice. If an assistant can make a provider's job easier and can help office staff to be as productive as possible, everyone involved with the practice will benefit—patients included!

First class

First class mail rates apply to almost all of the mail that is sent out by a medical office. First class mail covers letters, postcards, and the like. If mail is larger than letter size, it should be marked "First Class" to ensure proper, more expedient handling.

Priority mail

For documents and packages that need quick delivery, Priority Mail provides delivery service for items weighing up to 70 pounds, but this service is much cheaper than Priority Express Mail. Priority Mail is delivered within 1 to 3 days. Copies of records may consist of many pages and can be quite heavy. Local postal offices provide Priority Mail boxes, stickers, and envelopes at no charge. Priority Mail should be well marked to ensure proper handling by the U.S. Postal Service. The U.S. Postal Service also sells boxes for mailing small packages. Boxes are sold at a flat rate and include the price of the box and postage all in one fee, regardless of what the package might weigh.

Presort mail services

For practices that process large quantities of mail to specific ZIP codes, discount rates may be available for first class delivery services if a presort mail (also known as bulk mail) service is used. Presort involves sorting the mail by ZIP code before delivering it to the post office. Offices that have a high volume of first class mail can save a few cents for each letter that is sent at the presort rate. It may not sound like much, but in the long run, the savings really do add up!

Email Format

Formatting an email is pretty straightforward. The message can be sent, copied, or blind copied to someone. You must be exact when typing in the address. If there is even one small error in the address, a message will not be received. If you are working in an office environment, it is better to select an address from a network address book or personal address book or reply to an email to avoid the possibility of an error in the address. When identifying a subject for an email, be sure to be descriptive. Ever so briefly describe the purpose of the email within the subject line. If something needs immediate attention, use the term "urgent" in the subject line or identify the email as a high-priority email.

Headsets

Headsets are small devices that fit over the operator's head (Fig. 5.2) and direct sound into the operator's ears. Office headsets contain a microphone that allows the operator to carry on a complete conversation with the caller. Headsets are particularly useful because they allow operators to use their hands while on the telephone. The devices plug directly into the telephone or can be Bluetooth devices and can allow an operator to answer the telephone with either the handset or the headset. Using a headset is a good idea if an assistant is spending a large amount of time on the telephone. It is very difficult to balance a handset on a shoulder while trying to write a message or type information into a computer at the same time. A headset can also improve an assistant's ability to hear the caller. If a headset is not used, over time, a "shoulder balancing" posture may cause an assistant to develop a neck injury as a result of repeated incorrect posture. If a headset is used in a reception area where patients are assisted, many patients may not see that the assistant is wearing a headset and may begin to speak to the assistant while the assistant is on the telephone. When a patient approaches the desk, the assistant will have to allow the patient to see that the assistant is speaking with a patient on the telephone. Some offices even place a small device on the receptionist's desk that lights up when the assistant is on the telephone.

Leaving Messages for Patients

If a patient is not at home, the practice may prefer that the assistant leave a message for the patient. Depending on the nature of the practice and the wishes of the practice's physicians, however, a message may be left to ask a patient to return a call to the practice. Obviously, practices such as mental health clinics or other specialty treatment centers would not leave messages for patients because if the wrong person hears the message, the nature of the patient's treatment may be implied by the call. Offices should require a patient to sign a telephone release (Fig. 5.5). Such a release gives a health care facility permission to leave messages with a patient's family member, on an answering machine, or by voicemail. Even if a telephone release has been signed by a patient, an assistant should be careful to not leave detailed embarrassing information on a message. An appropriate message to leave in such a situation would be, "This is Walden-Martin Family Medical Clinic. Please call Taylor at 555-1234." In the absence of a telephone release, remember not to divulge any confidential information. Even with a release, you should exercise extreme caution when leaving a message for a patient. Excessive information in a message may cause embarrassment to a patient even if a family member receives the message. There is no way of knowing who may listen to the message. Some practices prefer to never leave a message for a patient. A message as simple as "Call Amy at 555-3424 about your appointment" may seem harmless enough but actually may cause problems if the patient does not want a spouse to know about the appointment. It is best to consult with the practice's physicians to establish a policy on leaving messages.

Two calls at the same time

If a practice has a multiple telephone line system, sooner or later two lines will ring at virtually the same time. Instead of answering and holding in the order the calls are received (e.g., line one, then line two, then going back to answer line one), holding can be cut by 50% by picking up one line, asking the caller whether he or she is able to hold, and then picking up the other line and speaking with that caller directly. Either line one or line two can be picked up first. Callers will not know whether they are on line one or line two. The main objective is to minimize the number of callers who are asked to hold.

A Pleasant Telephone Greeting

If answering the telephone were as easy as it was when we were young, this chapter would have ended much earlier. However, because a practice's business is so dependent on the telephone, and because patients' lives may be at stake when the telephone is answered, it is absolutely critical that each and every call is handled with a level of professionalism that is essential in a medical office setting. It simply is not enough to say "hello" and then wait for the caller to answer. When a call is answered in a medical office, you must speak clearly and slowly. Many operators say the office greeting much too fast, and that can leave callers wondering what was really said.

Physician out of the office

If the physician is out of the office and is unavailable, tell the patient, "Dr. Sanchez is not in the office, but Dr. Marks is taking her calls" or "She's out of the office until (date). May I take a message or transfer you to...?" Do not mention that the physician is on vacation unless the physician approves. The physician may not want "the whole world" to know she is not at home.

Processing Incoming Mail

In almost all offices, mail is received every day the office is open (excluding Saturday and Sunday). As mentioned previously, it may be delivered directly to the office or picked up at a post office box. Whatever the case, once the incoming mail arrives in the office it should be handled in an expeditious manner. Every piece of mail that comes into the office should be opened unless it is marked confidential. The exception to this is a confidential mailing, which should be opened only by the intended recipient. On opening the mail, letters and other personal documents should be stamped with the date on which they were received. A machine may be used to date stamp a document or a rubber stamp may be used to easily record the date on a document. In addition to the date stamp, sometimes a physician may prefer to have the envelope stapled directly behind the letter. After the date has been noted on the incoming mail, if the mail pertains to a patient, you should identify the patient's medical record number, and that information should be noted directly on the correspondence. The patient's medical record number can be written in black in the upper right-hand corner of the document. Letters and copies of medical records fromother facilities that are received will be filed eventually with the patient's medical record. After all record numbers have been located, the correspondence is sent to the physician for review. For health care facilities that use paper medical records, the correspondence will be paper-clipped or attached in some way on the outside front of the patient's record and then sent to the physician's office. If electronic records are used, the correspondence can be scanned and identified for review by the physician. It is important that all received correspondence regarding patients be sent to the patient's physician for review. Frequently, physicians ask their patients to obtain another facility's records for the patient's current medical record, and a physician may be waiting for this information, which may be vital to the care of the patient. After the mail has been dated and medical record numbers have been located, the mail is now ready for distribution inside the clinic. Because the volume of mail in most offices is considerable, it is a good idea to sort the mail into designated bins or slots for each physician or recipient (Fig. 5.12). Often, you may need to stop to assist a patient in the middle of sorting the mail. For that reason, it is a good idea to use some type of organizing receptacle for sorting the mail and not to have it strewn all over the desk. Some offices are so large that a central mailroom will sort and distribute all incoming mail to designated departments. Then assistants in each department will distribute mail to intended recipients. Medical information about a patient received in the mail should never be permanently entered into a patient's record without the physician's review of the information. If important information is filed in a patient's record without the physician's reviewing that information, a potential legal problem could result if the received information is needed in the treatment of the patient. After reviewing the correspondence, the physician should initial and date the correspondence in a conspicuous place to indicate that the physician has reviewed the document. An assistant should check to make sure that all documents have been initialed by the physician before filing the information in the patient's record. With an electronic records system, incoming information will be scanned into the patient's record. The scanned information can then be flagged to alert the physician to the incoming information. Once the physician has reviewed the information, the physician can electronically sign that the record has been reviewed.

Automated messages

In very busy offices, calls may be answered with an automated message if the telephone traffic is very heavy. Some offices prefer this to having the patient get a busy signal. Some offices may prefer to not use such a message because it may appear impersonal. Whether or not an automated system is used, it is imperative that emergency instructions be included in the message, for example, "You have reached Internal Medicine appointments. All lines are currently busy. If you are calling regarding an emergency, please hang up and call 911. Otherwise, please hold for the next available assistant." Some automated systems can give the caller a choice to route their call to the appropriate department. For example, the following message might be used: "Press 1 for appointments, press 2 to leave a message for a health care professional."

Body

Information to be communicated to the patient is included in the body of the letter. The body often will include at least three paragraphs: an introduction, a main message, and a closing. Three paragraphs are not required; some letters are much longer, or some may consist of only one paragraph. Whatever the case, the use of smaller, shorter paragraphs makes a letter much easier to read. If a letter is long and requires more than one page, a page notation should be used at the top of the second page to identify the addressee of the letter and other important information about the letter. This notation is absolutely necessary because a copy is made of all letters, and should the second page of the copy be separated from the first, it will be easy to identify where the second page belongs if a notation is present. A standard page notation includes the patient's name and medical record number, the page number of the letter, and the date the letter was written. The notation would look as follows: Marten, Lydia No. 12345 Page 2 June 1, 20xx

Letter Portfolio

It is a good idea to develop a portfolio of the varieties of letters written in the medical office. Simply saving copies of letters in a printed file or a computer file creates a letter portfolio. Later, when an assistant is asked to compose a letter, a portfolio provides excellent examples of letter "how-to's." A letter portfolio could contain examples for such letters as billing collection, instructions for specific procedures or tests, directions to a medical facility, or information on office procedures. When compiling a letter portfolio that is either electronic or printed, an assistant must delete any patient references in the letter—name, address, chart number, and any other identifying information—that may be confidential.

Switchboard

Larger practices will likely have a switchboard system that allows calls to be answered by a central switchboard operator (Fig. 5.4). Computerized switchboard systems are now available to help track the flow of telephone traffic within the office. Some switchboard systems allow calls to bypass the switchboard. This bypass can occur when the caller, instead of calling the main switchboard, dials an extension number directly. The call then goes directly to the intended recipient without having to be handled by the switchboard operator. Dialing an extension directly helps to reduce the number of calls handled by the switchboard. A direct dial number might be used to allow a hospital laboratory department to reach a clinic laboratory directly or vice versa. This type of call would not have to be handled by the switchboard. Using direct dial numbers greatly reduces the calls that are received at the front desk and thereby frees an assistant's time to handle other important office matters.

Business Letters

Letters in the medical office are written on 8.5 × 11-inch office letterhead. A letterhead contains the name of the medical facility and complete mailing address, as well as the telephone number(s) of the practice, along with any logo of the practice. If the practice is small, the names of the providers may be included on letterhead. Some very large practices with many physicians may choose to print the names of the physicians in a lighter ink on the back of the stationery. Some large practices choose to not place any physician names on stationery at all because the staff may change frequently, and the physician list will become outdated quickly. All written correspondence from a medical office should be written on letterhead. This gives a professional look to the information presented within the letter. Once a letter is typewritten, it is presented to the physician for signature. A copy of every letter containing medical information written to a patient is placed in the patient's medical record, and copies of all other letters (letters pertaining to the patient's account or finances) are filed in the appropriate office file.

Communications Equipment

Many different kinds of telephones are readily available in the marketplace. The size of the practice will dictate just how much telephone equipment is needed. Most offices require a telephone system with speaker or intercom connections that allow calls to be transferred within the office easily. A telephone with a minimum of two incoming and outgoing lines is necessary for even the smallest of practices to ensure that patients who call in are able to reach the office and that office personnel (physicians and nurses) and communications equipment (fax machines and computers) have outside telephone access. The telephone is not the only piece of communications equipment in the medical office. Many other devices work in conjunction with the office telephone or may operate independent of the office telephone.

Processing Outgoing Mail

Many types of services are available for sending mail. Postal rates vary considerably depending on the type of service chosen.

Components of a Letter

Many word processing packages provide templates or sample formats for easy letter and memo writing. A medical office also may choose to develop its own template to create a uniform format for all letters. Examples of letters are shown in Figs. 5.6, 5.7, and 5.8, with line spacing for each type of letter noted in the left-hand margin. Even though margins may vary, letters have many of the same basic components, and these appear within a letter in the following order. See Procedure 5.3 for a summary of how to prepare a letter.

Memos

Memos are internal communication pieces that are used in many offices. A memo allows information to be dispersed in an efficient format to other staff members in the office. Memos are used regularly to distribute routine information to employees regarding business procedures or occurrences. Memos may be written on blank sheets of paper or letterhead. It is inappropriate to write to a patient in a memo format. An example of a memo from a SimChart template is shown in Fig. 5.11.

U.S. Postal Service Delivery Services

Most of the medical office's written correspondence is handled through the U.S. Postal Service. The more common postal delivery methods used by medical offices include city delivery and post office box delivery. With city delivery, mail is delivered directly to the front desk or the central mailroom depending on the size of the practice. City delivery is convenient in that the postal carrier can leave the incoming mail, and outgoing mail may be picked up by the carrier to be taken to the post office. In a smaller office, mail may be exchanged with the postal carrier at the front desk or another designated location. The larger a health care facility, the more likely it is that there will be a designated mailroom within the building where outgoing mail is gathered to be sent out and incoming mail is received and distributed. Post office box delivery service is available for a fee at most post offices. Up to five different sizes of boxes may be available from which to choose, and the size of the box determines the cost. Mail in a post office box may be retrieved at any time while the post office lobby is open.

Postage machines

Most offices today have some type of postage meter or machine that stamps postage directly on envelopes or on postage meter adhesive strips. These adhesive strips are affixed to larger packages that cannot fit through a machine. Postage meters have a descending meter that tracks how much postage is left in the machine. When the postage left in the meter reaches a certain amount (sometimes less than $100), the machine automatically shuts off, and more postage must be purchased for the machine before it can be used again. Today's meters usually are connected online, and postage can be refilled online without a trip to the post office. A postage meter saves the office considerable time in that the mail may be weighed and stamped at the office and then deposited for delivery

Complaint calls

No one enjoys answering complaint calls, but think of a complaint call as an opportunity to regain the patient's confidence in the office. If you should have to handle a call from a patient who is unhappy, use these suggestions for handling complaints: • Acknowledge the patient's complaint. Even if the patient's complaint has no basis in fact, give the patient time to state his or her concerns. • Ask the patient what you can do to help. If you can help the patient, do so. If you cannot help, find someone who can. • Do not "pass the buck." Transferring the patient from person to person will only aggravate the patient. Help the patient if at all possible. • Keep your cool even if the patient is angry. This can be difficult to do, but no argument with a patient was ever won. • Do not make excuses such as "We're short-staffed today" or "The computer's down" or "We're so busy." All that these excuses convey is poor planning on the part of the practice. • Do what you can to make sure the problem does not happen again. Take the problem and ideas for potential solutions to your supervisor if necessary.

Written Communication

Not all business can be conducted over the telephone or in person, and, occasionally, an assistant will need to write a letter to a patient or a memo to office staff members. When communicating in written form, it is imperative that the assistant follow proper grammar rules. Your written word is a reflection of you and the practice. When correspondence is written, a good set of reference materials is a must. A well-stocked office library would include medical and English dictionaries, medical word books, pharmaceutical references, and style references such as The Gregg Reference Manual or another office style manual. These references will be used frequently to look up spelling and appropriate usage of terms, as well as styles of written correspondence. Many medical references are available online as well. Medical dictionaries and sites with medical information can be helpful for verifying spelling and correct usage of medical terms. Electronic medical references for computer systems also can be purchased.

Holding

Not all calls can be handled without asking a caller to hold. Of course, it would be best if no callers were ever asked to hold, but the reality is that you could be helping other patients in the office when the telephone rings. Some calls simply will not be handled without having the caller hold. The most important thing to remember when asking a caller to hold is that the caller must be asked whether he or she is able to hold. As mentioned previously, some calls may be an emergency and the caller should not, of course, be placed on hold. The appropriate way to ask a caller to hold would sound like the following: Operator: Good morning, Walden-Martin Family Medical Clinic. This is Amy. Are you able to hold? At this point, the operator must wait for a response. Note that the caller needs to be asked if he or she is able to hold. If it is an emergency, this gives the caller a chance to say so. If it is not an emergency, the caller can say yes or no. The caller may say no to holding for various reasons. Maybe the caller needs only to be transferred or, possibly, the caller is calling long distance. A caller should never be "told" to hold, as in "Please hold." This statement is a command and gives little opportunity for the caller to respond if he or she is not able to hold. Always give the caller a choice. If a caller is placed on hold, a reasonable period to expect a caller to hold is no longer than 1 minute. One minute can seem quite long. After 1 minute, if the caller needs to be on hold for a little longer, the assistant should answer the line again and ask the caller whether he or she can continue to hold, or if the assistant may call the caller back. Some telephone systems even have a feature that re-rings a call that has been on hold for a specific length of time. When the assistant is returning to answer a call that has been on hold, an appropriate introduction would be, "Thank you for holding. How may I help you?" When the office is busy and incoming calls may have to hold, an assistant should wait until just after the third ring to answer the call and then should ask the caller to hold. If the assistant answers on the first ring and asks the caller to hold, that might give the impression that calls are not a big priority of the practice. By waiting just past the third ring, the caller is aware that the practice may be busy at the moment.

Notations

Notations include information written mainly for the sender of the letter. Who dictated and transcribed the letter and who received copies of the letter and information included with the letter are examples of information included in various notations. Notations begin two lines below the author's name and appear in the following order: • Reference initials. These include the initials of the author and of the transcriptionist. The author's initials are capitalized and the transcriptionist's initials appear in lowercase letters. A slash is used to separate the initials, for example, TM/bp. • Computer file name notation. Because virtually all letters are electronically prepared with word processing software, an office can quickly store a multitude of letters in a computer system. Sometimes after a letter has been transcribed, a physician may make changes within the letter. Those changes can be made quickly if the letter has been stored. File names should be systematically assigned according to a uniform format and should be meaningful. For example, 091017olson28632 could be used to identify the date the letter was written and the last name and medical record number of the patient. Both the chart number and the last name would identify a specific individual to whom the letter was written. The date would be necessary to differentiate the file name from previous letters sent to the patient. • Enclosure notation. This notation identifies whether or not anything is included with the letter. If a physician has stated something in the letter such as, "I have attached a copy of your lab report" or "A prescription for Diovan is enclosed," this would indicate to the transcriptionist or the assistant that an enclosure notation should be added to the letter. The notation would then alert the individual responsible for sending a letter that something should be included with the letter. • Copy notation. A copy of every letter will be included in the patient's medical record. This is NOT the purpose of a copy notation. The copy notation indicates whether another individual other than the addressee is to receive a copy of the letter. This notation is simply the letter "c" followed by a colon and the name of the party who is to receive the copy, for example, c: Donna Burley, MD. Refer to Fig. 5.8for an example of how all of the above notations are used. Historically, copy notations were identified as "cc:" which stood for carbon copy. Thankfully, the use of carbon copies is a thing of the past and the use of "cc:" has been changed to "c:."

Identifying emergencies over the telephone

Occasionally, a patient (or a relative of a patient) may telephone the clinic with a serious problem that may constitute an emergency regarding the patient's health. The person who is phoning in may or may not realize that the symptoms could pose a serious threat to the health of the patient. The medical administrative assistant must be aware of symptoms that could constitute a potentially serious health situation. An emergency may be defined as a situation in which a patient's health might be adversely affected if immediate action is not taken. Box 5.1 outlines some critical symptoms of which an assistant should be aware. This is not an all-inclusive list but is designed to introduce you to some of the more common symptoms that may indicate an emergency situation. An assistant should review the list with the physicians in the practice to determine whether the physicians feel the list is inclusive enough for their office. When you receive a questionable call in the clinic, you should be careful to not diagnose the patient, alarm the patient, or place the patient at undue risk. If a patient calls in with chest pain, before taking a message or making an appointment, an appropriate response by the assistant would be, "I'd like to have you speak with the nurse before I take a message" or "I'd like to have you speak with the nurse before I make an appointment." The patient should never be told something like he or she might be having a heart attack. That statement may be interpreted as diagnosing the patient. The assistant also should be careful to not ask too many questions because the patient may feel that the assistant is prying and because the number of questions asked may frighten the patient. The patient with a possible emergency also should not be told to go to the emergency department. Imagine what might happen if a patient gets into his or her car and drives to the emergency department. If the patient is having a heart attack, he or she could go into cardiac arrest while driving and die on the way to the hospital. Someone who is experiencing a possible heart attack or any serious medical emergency should never be behind the wheel of a car. When the physician or nurse speaks directly to the patient and determines that the patient may be in a life-threatening situation, the physician or nurse will instruct the patient to call 911 immediately. If you are wondering whether a situation is a potential emergency, remember this rule: When in doubt, check it out! Do not be afraid to check with the physician or nurse regarding any situation that you are unsure about.

Call confirmation

Once the caller has been assisted, it is important to confirm any necessary information. If an appointment is scheduled, the provider, the date, and time of the appointment should be confirmed with the caller. If a message was taken, the message written should be repeated verbatim to the caller to ensure that it accurately reflects the wishes of the caller. If appropriate, ask the caller if he or she has any questions. You should inform the caller of the action that will be taken to address this call.

Caller identification

Once the reason for the call has been identified, the assistant will ask for the caller's name. Once the reason and the caller have been identified, the assistant will be able to decide how to handle the call based on the protocol that has been established for the office. Table 5.1 lists a sample telephone protocol that includes the various types of calls that are received in a medical office, the action an assistant should take, and who is ultimately responsible for completion of the call.

Priority mail express

Priority Mail Express is the fastest delivery service offered by the U.S. Postal Service, but one of the more expensive. Most express mail packages are guaranteed delivery overnight. Usually, mail must be brought in by 5 PM to qualify for overnight express mail service. Delivery is made by 3 PM the next day. Express mail may be deposited in an express mail delivery box, taken to a local post office, or picked up by the letter carrier. The U.S. Postal Service provides containers and mailing labels for express mail packages at no charge. Packages can weigh up to 70 pounds, and the rate stays the same no matter what the package weighs. Because of the excessive cost of express mail, it should be used only when a package requires expedient delivery.

Private courier services

Private courier services such as FedEx or United Parcel Service (UPS) provide alternatives to services offered by the U.S. Postal Service. Private couriers usually specialize in certain types of delivery, such as overnight delivery or package services. Different rates are available depending on what type of service is needed.

Communication Concepts

Professional communication skills are essential for everyone in the medical office. Professional communication is courteous and respectful whether you are working as part of the administrative or clinical staff. The ability to communicate effectively with patients is vital for all medical office personnel. Communicating with patients in a professional, business-like, yet caring manner fosters trust between the medical office staff and the patient and lays the foundation for a strong, trusting, and long-lasting relationship between the patient and the practice. Even the most beautiful physical surroundings cannot make up for any staff member who lacks proper communication skills. A medical administrative assistant frequently interacts with patients, and this interaction has a great impact on the success of the practice. Whether an assistant is communicating with a patient face to face, on the telephone, or in writing, the assistant's communication must be professional and should continually reflect the image that the practice wishes to project.

Incoming Calls

Responsibility for managing the telephone traffic in a medical practice is an important matter. If more than one line is coming into the office, managing incoming calls can be very challenging. While an assistant is speaking on one line, one or more calls may come into the office on other lines. Depending on the size of the practice, one assistant may be assigned to handle the telephone on a full-time basis. The need for telephone coverage can vary depending on the time of day or the day of the week. Certain days of the week, particularly Monday and Friday, can have especially heavy telephone traffic. Mondays bring calls of people who were ill over the weekend, and Fridays bring calls of people who need medical care before the weekend. Because of the unpredictability of telephone traffic, any assistant or medical office employee should be ready to answer the telephone whenever needed. Procedure 5.1 details the essential components of a telephone conversation in the medical office.

Telephone Services

Several additional services may be available from local telephone companies. These services may enhance the customer service that the office staff is able to provide. The practice will have to weigh the potential benefit of the services versus their costs. The following services may be of benefit to a medical office: • Caller ID. Caller ID features are available on many phones. Caller ID displays the number and the name of who is calling before the call is answered. • Three-way calling. This feature allows three parties in three separate locations to speak simultaneously. This may be particularly helpful in telephone conferences among one or more physicians, a patient, and one or more family members. • Call forwarding. Calls are forwarded from one telephone number to another. If a medical office is closed during a vacation, calls may be forwarded to another physician's office that may be taking calls for the physician. • Conference calls. With this feature, several individuals at different locations may speak with each other simultaneously. Three or more parties at separate locations can be connected on the same call. Communications technology is constantly changing and is growing at almost an exponential rate. Video calls over an Internet connection enable callers to see each other while talking. Texting is a common feature for cell phone users, and this application is being used by medical offices to communicate with patients.

Transferring calls

Some incoming calls will require transfer to another staff member. When transferring, the assistant should ask the caller whether he or she can hold so the call can be transferred. The assistant should let the caller know to whom he or she will be transferred. Also, when signaling the location or the person to whom you are transferring, you should announce or introduce the caller, such as "Dr. Marks, Mr. Olson is on line 1." A proper call transfer might sound like this: Assistant: Are you able to hold while I transfer you to Dr. Pearson's nurse, Donna? Caller: Yes. (Caller then is placed on hold.) Assistant (signals nurse's station): Donna, Jane Doe is on line 1. Important things to remember when you are transferring include the following: • Ask the caller if you may transfer the call. • Explain to the caller what you are going to do: "Can you hold while I transfer you?" • Announce the call: "Dr. O'Brian, Mrs. Johnson is on line one." • When signaling the nurses' station via a speaker telephone, remember that it is possible people in the area may be able to hear. If a speaker telephone system is used, never, ever give sensitive information over the speaker. Something like "Mary Johnson is on line 1 for the results of her pregnancy test" is absolutely inappropriate. Obviously, this would embarrass some people, but, more important, it is a breach of confidentiality. A better way to transfer such a call is, "I have a patient on line 1 for the results of her lab work."

Certified with return receipt

Sometimes it is necessary to have proof that a letter or package has been mailed and received. In this case the letter should be sent certified with a return receipt (Fig. 5.13). This service assigns a number to the delivery and requires that a signature be obtained at the time of delivery. This service is necessary to document important notifications to patients, such as withdrawal of medical services.

Personality Styles

Sometimes, we can be doing everything right in communicating with others, but we may get mixed responses from various people. Have you ever noticed how people can interpret or respond to the same situation differently? These responses may be due to personality differences among individuals. People can be introverted or extroverted. Some people love working with large groups of people, while some may be uncomfortable in a large group and may prefer working alone. Would you like working in a busy, hustle-bustle office or a quiet office? Not everyone has the same likes and dislikes, and individuals respond differently to different situations. This does not mean that one is right and one is wrong; this may just reflect personality differences. What is important is that we respect the opinions of others just as we would wish to be given the same respect in return. Think about it this way: Isn't it great that we all aren't the same, so that there are people who are well suited for different types of positions? If everyone was the same, life would get dull and boring pretty quickly. Personality differences sometimes can lead to conflict in the office. When presented with a conflict, it is important for each individual involved to respect the rights of others. People have differing opinions or different ways of looking at things, and we need to accept those differences. Such action is a mature response to these situations and goes a long way in ensuring that the office runs smoothly.

Envelopes

Standard size No. 10 business envelopes are used for business correspondence. Fig. 5.9demonstrates the proper format for addressing a business envelope. For addressing an envelope, the U.S. Postal Service has suggested these specific guidelines, which should be followed to allow envelopes to be easily read by an automated mail processing machine known as an Optical Character Reader (OCR). The U.S. Postal Service reads addresses on 99.5% of mail that has typewritten addresses. The OCR can even read addresses that are handwritten. A complete list of the postal addressing standards can be found in Publication 28 by the U.S. Postal Service. • Use all capital letters with no punctuation. Refer to Fig. 5.9. • Use black ink on white or light-colored envelopes. • Fonts should be simple to read. Fancy fonts are difficult for machines to pick up and will cause delays in processing mail. Use at least a 10- to 12-point readable font. • Left justify the address. • Use one space between city and state and one space between state and ZIP. • If using labels, be sure that labels are complete and that addresses haven't been cut off. Make sure labels are on straight. • When you are addressing a letter with an attention line, put the attention line at the top of the address, for example,ATTN DR MARIA SANCHEZWALDEN-MARTIN FAMILY MEDICAL CLINIC1234 AnystreetAnytown, Anystate 12345RELEASE OF INFORMATIONWALDEN-MARTIN FAMILY MEDICAL CLINIC1234 AnystreetAnytown, Anystate 12345 • Use the free online ZIP code lookup of the U.S. Postal Service, which is located at https://www.usps.gov. When the letter is placed in an envelope, the letter should be folded in thirds and inserted as indicated in Fig. 5.10. This method of folding allows the letter to be removed easily when received and to be read by the recipient.

Communicating With Your Supervisor

The best relationships between supervisors and staff are those in which there is a healthy mutual respect. In some practices, the physician is the assistant's direct supervisor. In larger practices, an office supervisor usually is hired to oversee the business functions of the office. Regardless of who is the supervisor, it is important to remember that the supervisor is the person in charge, and the supervisor is ultimately responsible for the operation of the office. When communicating with a supervisor, an assistant must be respectful of the supervisor's position and should strive to meet the expectations of the supervisor. It is important for you to bring to a supervisor's attention any problems or concerns that you cannot handle. Do not think that a problem will go away if it is ignored. Do not guess at what might be the solution to the problem. A supervisor and an assistant who work together will help the office run smoothly. A harmonious work environment will enhance services provided for the good of the patient and will promote a strong, successful practice. Remember the words of the Mayo Clinic founders: "The best interest of the patient is the only interest to be considered." We are all in it for the patient!

Date

The date should be formatted as follows: June 15, 20xx. Some physicians may prefer to use a military date, for example, June 15 20xx. A format such as 6-15-xx is not acceptable for a business letter. If a physician dates a letter, the date of the letter will be the date that the letter was dictated, or a date otherwise specified by the physician. If a member of the office staff is creating and preparing a letter, the date on the letter usually will be the date the letter was prepared. The date line should start at between 2 and 2.5 inches from the top of an 8.5 × 11-inch sheet of paper. The length of the letter will determine where the date is placed. A longer letter will include the date closer to the 2-inch mark because the letter will take up more of the page. It is possible and preferable to adjust the top and side margins a bit in order to fit a letter onto one page. A one-page letter is preferable because a two-page letter may possibly end up with the pages separated.

Welcome

The first portion of a telephone greeting is a pleasant statement, a welcome, such as "Good morning" or "Thank you for calling." These introductions are a pleasant way to start a conversation with a caller, and they help establish a pleasant foundation for the conversation with the patient. In addition, a welcome greeting alerts the caller that the call has been answered and helps prepare the caller to commence a conversation. Welcomes such as "Merry Christmas" or "Happy Hanukkah" and others with obvious ties to religious holidays are not used in some office settings. The larger the organization, the more likely that greetings will be generic in nature. In a smaller office, a physician's personal preference will determine how calls may be answered. Why is such a thing even important? A simple holiday greeting could offend patients of one religion if the greeting references another religion.

Proper Telephone Technique

The foundation of good telephone communication skills is a good telephone personality. Your choice of words, volume and tone of voice, and general expression on the telephone will have a tremendous impact on patients. A caring, pleasant-sounding, customer-friendly, service-oriented personality is essential in telephone communication in any medical office. Many of us, at a very young age, learned to answer the telephone. Answering the telephone in a medical office is quite different from answering a personal telephone because it carries a great deal of responsibility along with it. A patient may reveal sensitive, confidential medical information over the telephone. A patient may call the office with a potentially serious medical situation. Responsibility for answering the telephone in a medical office must be taken seriously, and as the medical administrative assistant, you will be required to continually make the right decisions when communicating on the telephone.

Components

The heading of a memo contains four basic pieces of information. The first item is to whom the memo is sent, followed by from whom the memo was sent. Next, the date is listed, followed by the subject of the memo. After the heading is completed, the body of the memo is typed in paragraph form. Reference initials belonging to the person who keyed the memo, and a computer file name can be added below the body of the memo.

Inside address

The inside address consists of the complete name and address of the person to whom the letter is being written. This person is known as the addressee. The correct format of the inside address is as follows: Ms. Lydia Marten 607 Sweet Avenue Harvester, MN 55555 In cases in which information is sent regarding a minor, the letter should be addressed to the child's parent or legal guardian.

Modified-block style

The modified-block style differs from the block style in that the date, complimentary closing, and author's signature begin in the center of the page. The remaining information is flush with the left margin (see Fig. 5.7). If the author prefers to indent the paragraphs in the body of the letter, this type of letter is known as a modified-block style with indented paragraphsor a semiblock style (see Fig. 5.8).

Salutation

The salutation is a greeting to the addressee. An acceptable salutation for most business letters would include a title such as Mr., Mrs., or Miss, along with the patient's or theguardian's last name; this would appear as follows: Dear Ms. Marten. If the physician knows the patient well, he or she may choose to use a more personal salutation such as Dear Lydia.

Subject line

The subject line appears below the salutation and above the body of the letter. The subject of the letter is written after the colon. In a letter to a physician regarding a mutual patient, the subject line might read: Subject: Mrs. Alice Shepard. In a letter to a patient, the subject line would probably contain the main purpose of the letter (e.g., your recent thyroid test results). The purpose of using a subject line is to enable all medical office personnel to quickly identify the chief reason for the letter. This could be a time-saving device if there are many letters within a patient's file.

Telephone Communication

The telephone is an indispensable piece of equipment in the office today. Most of a practice's business is conducted over the telephone. Appointments are made, patients call to inquire about health concerns, office staff members use the telephone to conduct business, and a multitude of other office activities require the use of a telephone. However, just because someone knows how to pick up the telephone and say hello, it cannot be assumed that the telephone will be used properly.

Communicating Effectively

The vast majority of people in this world can talk, but can they communicate? Are they understood? Consider this example. If you and a friend are outside one day, and your friend remarks, "The sky is blue today," you know that your friend thinks the sky is blue and not green. But imagine if your friend says, "Look at the sky"; you may be able to guess that your friend wants you to notice that the sky is blue, but it is possible that you may be looking for something in the sky, such as an airplane or a bird, or perhaps you may notice a cloud with an interesting shape. This example illustrates how important word selection can be in the communication process. Consider this next example. A patient enters the office and begins to speak to you in German. The patient is talking, but if you do not know German, very little communication may occur. At the very least, you will not be able to understand what the patient is saying. But if you have a very puzzled or confused look on your face and respond in English, your facial expressions and verbal response should communicate to the patient that you do not understand German. From the examples mentioned, the basic components of the communication process are evident: a sender, a receiver, a message, and feedback. The sender and the receiver are the two parties to the proposed communication, the message is the information from the sender, and feedback is the information the receiver gives to the sender about the message. Let's look at another example in a medical office setting. Suppose a patient calls the office and reports to the assistant that he or she is not "feeling well." This statement does not give the assistant a clear indication of what the problem might be. Consequently, if the assistant relayed this information to a nurse or to a physician, it would not be very helpful to either one because it is not very descriptive. If the patient reports, however, that he or she has had a sharp, stabbing-like pain in his or her lower right side for 2 days, this gives a much more accurate picture of the patient's condition. Unfortunately, not every patient may describe symptoms this well, which is why medical administrative assistants benefit from cultivating good communication skills. In the previous situation, if a patient states that he or she is not "feeling well," it is the medical administrative assistant's responsibility to determine the general nature of the patient's problem. This is necessary to determine what type of action should be taken with the patient's call. In this case the assistant could ask the patient to describe their symptoms. The description does not have to be in great detail, but information about type and location or pain and how long the pain has been occurring would be very helpful to a health care provider who responds to the patient. When communicating with a patient, it is imperative to obtain a clear picture of what the patient is trying to say. One of the most important things a medical administrative assistant can do, and one of the most essential components of effective communication, is to listen to the other person while he or she is speaking. This is known as active listening. Active listening involves devoting all your attention to the patient and actually doing more listening than speaking. Be attentive by giving 100% of your attention to the patient, whether the patient is in the office or on the telephone. Do not plan what you might say while the patient is speaking. Give the patient ample opportunity to say what he or she needs to say. After the patient has finished speaking, ask any questions that may be necessary to clarify the situation. Using the previous example, let's see how a medical administrative assistant might handle a patient's comment about not feeling well. Patient: I'm not feeling well. Assistant: What kind of symptoms are you having? Patient: I threw up this morning. Assistant: Is that the only symptom you've had? Patient: I've also had a sharp pain on my lower right side. Assistant: How long have you had the pain? Patient: A couple of days. Assistant: And have you had any other symptoms? Patient: Just a slight fever. The medical administrative assistant in this case has obtained just enough information to convey a picture of the patient's condition to the nurse or physician. It is not necessary for the assistant to get every last detail about the patient's illness from the patient. The assistant simply needs enough information to give the medical staff a clear picture of the patient's condition and to determine whether the call needs immediate attention from the medical staff, if an appointment can be made, or if a message can be taken. In the preceding example, the patient might have appendicitis, which is a serious condition that must be brought to the attention of the physician immediately. If the assistant had stopped asking questions after the patient reported vomiting, the assistant would not have been given enough information to illustrate the seriousness of the situation. When questioning a patient, an assistant must be extremely careful to identify any serious or potentially life-threatening conditions without alarming the patient. It is important to avoid saying anything that could be construed as attempting to diagnose the patient's problem. Patients who report serious conditions or symptoms should be referred to the physician or nurse without delay. Identifying and handling emergency calls is discussed in greater detail later in this chapter. Previous examples clearly illustrate the importance of communication in the medical office. Because of the nature of the calls that come into the office, good communication may in some cases mean the difference between life and death to a patient.

Pager

Very often, a physician may need to be contacted when not in the clinic. A pager can be used to reach physicians in such instances. To reach a physician using a pager, an assistant simply needs to call the pager's telephone number and leave a message. Depending on the type of pager service, the assistant may leave a verbal message or may enter a telephone number for the physician to call. An important point to remember when leaving a verbal message is to maintain patient confidentiality. You will not know exactly where the physician may be when the message is played, so do not leave any message that could cause embarrassment to a patient.

Communication Basics

When applying professional communication techniques to interactions with patients, it is important to understand basic communication concepts. The Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing, & Allied Health defines communication as the "sending of information from one place to another." One of the cornerstones of understanding communication is the idea that communication involves getting that information, idea, or thought from one individual to another. Communication is an enormous topic. Entire courses and degrees are necessary to address the many nuances of this subject. This chapter addresses many of the critical componentsnecessary in laying a foundation for effective communication within the medical office. Additional study of communication beyond this chapter would enhance your ability to communicate effectively with patients and other individuals in the medical office.

Taking messages

When reviewing the telephone protocol in Table 5.1, you will note that many calls require that a message be taken. When taking a message, enough information must be obtained from the caller to ensure that the call is handled properly. Remember that a message is taken to help the patient in some way, and that complete, detailed information will be needed to assist the patient as much as possible. With today's electronic health record (EHR) systems, telephone messages become part of the patient's medical record. A patient's health medical record is a legal document, and it is critical that you realize that the actual message you are writing will be a part of a patient's permanent medical record. Paper message blanks themselves can be directly adhered to the medical record. Messages are written on a full, half, or quarter sheet of paper, and the physician or nurse will document their response to the message. If the patient's message is recorded in an EHR system, these systems allow both messages to be taken and transmitted to the intended recipient electronically. No paper needs to be used at all. The same information is required for an electronic message as a written message, but instead of a slip of paper being sent to a physician, the message is created within an EHR system and is sent electronically to a physician via the office's computer system. Even electronic messages will become part of the patient's medical record (Fig. 5.3).

Patient Portals

With the increased use of computers today, many patients frequently use email to contact a medical office. Patients may be able to contact an office within a secure email system through the office's website, known as a patient portal. Patient portals enable patients to request appointments, check in for appointments, review test results, and view documentation in their record. Because the security of the email environment may possibly be compromised, highly confidential information cannot be included in email communication with patients. If a patient does email an office with a health-related concern, the email and the staff's response to the email should become part of the patient's medical record.

Identification of the facility or department After extending the welcome, the operator should identify the facility or department by name.

• "Good morning, Walden-Martin Family Medical Clinic..." • "Good afternoon, Walden-Martin Family Medical Clinic..." • "Thank you for calling Walden-Martin Family Medical Clinic..." • "Good afternoon, Dermatology..." • "Thank you for calling today. This is Cardiology..." Complete identification of the office name or department is necessary to assure the patient that the correct location has been reached. Even if the call has been received at a central switchboard and then transferred to a specific department (e.g., neurology, pediatrics), an assistant still should identify the department by name when answering, such as "Hello, Pediatrics..." or "Good Morning, Physical Therapy Services..." Identifying the facility or the department lets the caller know that the correct location has been reached.

Every call that comes into the office should be answered with a cheerful greeting consisting of three to four components: (1) welcome, (2) identification of facility, (3) identification of operator (assistant's name), and (4) an offer to help. Appropriate greetings may sound like the following:

• "Good morning, Walden-Martin Family Medical Clinic; this is Annie. How may I help you?" • "Thank you for calling Walden-Martin Family Medical Clinic; this is Mike. How may I direct your call?" • "Good afternoon, Walden-Martin Family Medical Clinic; this is Rosa. How may I help you today?"

In addition to learning proper telephone technique, you must be aware of some special considerations when you answer the telephone in a medical office:

• Consider telephone location. The office telephone should be located on the assistant's desk within an arm's reach of the office computer. Many times, you will be speaking with a patient on the telephone and will need to access information from and input information into the computer during your conversation. If the lobby is close to the front desk, you will have to be careful that patients in the lobby do not hear your voice. • Maintain confidentiality. Because the office is often a busy place with patients stopping at the front desk for assistance, you will have to be sure not to divulge a caller's complete name or disclose medical information in front of another patient. All telephone conversations must be kept confidential. • Keep conversations brief. Because many offices do get a tremendous volume of calls, be mindful of the time that is spent on the telephone. You must be sure to give the patient the time needed, but be sure that it is time well spent in getting information for a message or assisting the patient in another way. • Do not ignore a ringing telephone. If the office is extremely busy and it is difficult to answer the telephone, some practices may be arranged in such a way as to allow other staff members in the facility to assist in answering the telephone when the telephone traffic becomes too heavy. • Answer incoming calls in three rings or fewer. If the telephone cannot be answered as soon as it rings, be sure to answer within a reasonable time. If the telephone is allowed to ring four to five or even more times, many callers may begin to wonder whether the office is open or whether the practice cares about patients who call. • Do not give medical advice or ask questions that may lead a patient to believe that you may be diagnosing the patient's condition. For example, if a patient calls to report severe right lower quadrant abdominal pain, never say, "It sounds like you have appendicitis" or "Have you ever had problems with your appendix?" Both of these statements could be interpreted as practicing medicine without a license (which is illegal) and could result in immediate dismissal from employment. • Do not use the office telephone or a personal cell phone for personal business while on duty.This is unprofessional behavior. Always wait for lunchtime or a break to make personal calls.

Think about your own body language. What kind of nonverbal signals are you sending every day? Are they positive or negative? Cultivate positive body language habits and you will have contributed to an inviting atmosphere for patients. Practice the following every day:

• Establish eye contact. Nothing conveys sincerity in a conversation more than a person who looks directly at someone else. Be aware that some individuals, as you learned in Chapter 4, may avoid eye contact with you because of cultural influences. • Be conscious of your arm position. Are your arms crossed in front of your body, creating an almost protective or possibly hostile barrier between you and another person, or are they casually at your sides or in use? • Smile, smile, smile at all times when appropriate. Cheerfulness goes a long way in making the patient feel welcome in the office. • Watch your posture. When talking with a patient, the front of your body should be directed toward the patient. Do not talk with your back to the patient. • Watch facial expressions. Frowning sends an obvious negative message. • Be aware of a patient's comfort zone. Leaning in too far to speak to a patient or positioning yourself closer than a few feet from a patient may invade his or her personal space and may make the patient feel uncomfortable. A distance of 18 to 24 inches is a comfortable distance when conversing with a patient. • Be aware of the impact of personal attire and grooming. Professional appearance makes a significant impression.

Be careful where you speak to a patient. Protected health information about a patient includes the following:

• Patient's birth date, address, telephone number, medical record number, Social Security number, and any other identifier that could specifically identify the patient • Any information that health care providers put in the patient's medical record • Billing information about the patient • Patient information stored in a computer

If you receive a call regarding a patient who is experiencing any of the symptoms listed here, a medical professional should assess the situation immediately.*

• Shortness of breath • Chest pain or pressure • Pain in upper left arm • Extreme dizziness or complaints of vertigo • Loss of consciousness • Serious injury or trauma such as broken bones or head injury • Sudden numbness or tingling • Blurred vision • Slurred speech • Severe, unrelenting headache • Profuse, uncontrolled bleeding • Acute abdominal pain

When speaking with patients, follow these basic guidelines for effective verbal communication:

• Speak clearly. Chewing gum or eating any type of food while at the front desk is unacceptable. • Speak loudly enough so that patients can hear but not so loud that everyone else hears. • Pronounce words correctly. • Speak with a caring, pleasant voice. The sound of your voice conveys a message. Others can tell whether you are genuine in your responses or whether you are uninterested and uncaring. What kind of feeling does your voice convey? Is it one of caring, or is it one of indifference? • Monitor the speed of your speech. Do not speak too fast or too slow. • Direct your words to the individual to whom you are speaking. • When speaking with patients, be aware that you are a representative of the practice. Patients will interpret what you say as coming directly from the physician. • Ask enough questions to identify the needs of the patient. Do not ask so many questions that it may appear you are prying into the patient's private health matters, or it may alarm the patient. • Be careful to protect confidentiality when speaking with a patient. • Never, ever suggest to a patient what might be wrong. This is practicing medicine without a license and is punishable by law! • Clarify the patient's needs by repeating the patient's request or statement. Clear up any misunderstandings. Say to the patient, "Let me make sure I have this right..." • Do not interrupt. Give the patient ample opportunity to convey thoughts without interruption. • As mentioned in Chapter 4, technical medical terms and jargon should be used only if the patient uses them in conversation, or if the patient is a health care professional.

Many of the same rules mentioned previously for good communication apply to communicating via the telephone. When speaking on the telephone, practice the following professional telephone techniques:

• Tone and volume of voice. Speak in a tone that is thoughtful and caring. Speak loud enough for the patient to hear but soft enough so that others in the office will not hear. If appropriate, smile while talking on the telephone. Patients will notice the pleasantness of a smile reflected in your voice. • Quality of your speech. Consider the words used in your conversation. Avoid slang, use proper grammar, and maintain professionalism while on the telephone. • Proper telephone posture. You should sit upright (no slouching!), hold the handset or headset microphone 1 to 2 inches away from the mouth, and be sure to enunciate clearly (Fig. 5.2). In most medical offices, there is considerable background noise, and to be heard well, you will have to be attentive to the patient on the other end of the line and speak directly into the handset. Proper posture at the telephone will help ensure that you present your best self when you are speaking with a patient over the telephone. • Speed of your speech. Be careful to speak at a rate that will be understood by the caller. Depending on your interaction with the caller, you may have to adjust your speech rate to be sure that both of you are communicating. Routine information that is repeated many times to various patients may be well understood by you, but it may be the first time the information is heard by the patient. Be sure to give information in a way that is understood by the patient.