Chapter 22, 23, 24, 25 & 26
streaming
appointments are scheduled for a particular amount of time based on patient's need.
C
canceled
CP
chest pain
CONS
consultation
charge slip, encounter form, superbill
document used to record the services provided to a patient.
ECG
electrocardiogram
FU
follow-up
NP
new patient
open hours
no scheduled appointment. patients sign in upon arrival and are seen by the provider.
NS
no show
Subjective information
not seen by the examiner; information supplied by the patient
P + P
pap and pelvic
Wave?
patients are scheduled during the first 30 minutes of each hour, leaving the last 30 min for same day appointments.
PT
physical therapy
RE
recheck
REF
referral
flex time
refers to the practice of permitting work hours within a range of time.
RS
reschedule
modified wave
scheduled the same as wave but with the exeption of scheduling the patients in the last 30 minutes at 10-20 minute intervals.
Clustering
scheduling patients for specific type of visits or procedures at specific times.
What is clustering?
scheduling patients for specific type of visits or procedures at specific times.
referral
sending a patient to a provider of a different specialty for treatment beyond their scope of practice.
SIG
sigmoidoscopy
SURG or Sx
surgery
S/R
suture removal
no show
term used to describe a visit in which a patient fails to present for examination without giving the provider advance notice.
privacy officer
the person designated by a healthcare organization, whether hospital system or private practice, who handles and oversees the maintenance of protected health information.
chief complaint
the problem; reason for the patient's visit.
obliterate
to blot out; leave no trace; destroy.
purge
to empty;clear.
utilization
to put to profitable use.
unstructured
without specific arrangement.
What is BP?
Blood Pressure Check
NP?
New Patient
Subjective
Of a disease symptom, felt by the individual but not perceptible to others Relating to the person who is thinking, saying or doing something Personal
Purge
To empty; To cleanse of impurities; Clear
single-booking
a method of scheduling in which only one patient is assigned to one block of time in a visit schedule.
audit trail
a record of transaction that identifies which what person(s) and at what time and day an electronic record was accessed in order to maintain accountability for the security of theinformation as it is accessed.
C+C
called and cancelled
CPE/CPX/PE
complete physical examination
Impression
'I' in HPIP means
Plan of care
'P' in SOAP means
Complete and accurate medical record
A _______, provides protection for both the physician and patient.
Tickler File
A chronologic file used as a follow-up method for a particular date; may be an expanding file, a card file or even a portion of a file drawer
Indexing
A system of cross-referencing information contained in office files so that the data may be searched using different characteristics as the query term
Problem-oriented medical record (POMR)
A system of recordkeeping used to collect specific pieces of information regarding a patient during a healthcare visit, such as patient profile, chief complaint, review of systems, physical exam, lab reports, chronic problems, medication and preventive care lists and patient education
C & C?
Call and Cancel
C?
Cancel
CP?
Chest Pain
patient's own words
Chief complaint should be written in _______
CPE?
Complete Physical Exam
Cons?
Consultation
Ethnicity
Demographic term that indicates with what societal group a patient identifies himself/herself
F.U. ?
Follow Up.
Objective information
Is seen on examination; findings by practitioner
Chronological order
Lab information should be filed in _______
Lab?
Laboratory
Walk-in/open hours?
No scheduled appoint. patient signs in upon arrival and are seen by provider in that order.
What should you do when you recognize that patient in the waiting room will be required to wait much longer than originally expected?
Notify the patient tactfully, offer to reschedule the appointment for another time.
Objective
Of a disease symptom, perceptible to persons other than the one affected The end toward which action is directed On a microscope, a lens or series of lenses
Past medical records
Patients have a legal right to their medical information, but th chart belongs to the provider or practice
What is informed consent?
Patients never undergo invasive procedures without this. Makes patient aware of risks/benefits of procedure.
Subjective objective assessment plan (SOAP)
Process makes chart easier to review and helps in follow up of all problems patient might have
What do you do if a patient appears reluctant to complete the intake forms?
Quietly offer to assist in a closed room (privately)
Progress notes
Record of the continuing progress and treatment of a patient
History Physical Impression Plan (HPIP)
Recording of medical information; H--History (subjective findings); P--Physical exam (objective findings); I--Impression (assessment/diagnosis); P--Plan (treatment)
Progress notes
Records all interactions with office and progression during treatment.
Ref?
Referral
Documentation
Refers to both the act of preparing or the evidence created when a healthcare professional records, information regarding a patient during the course of assessment and treatment; Can be handwritten or electronically
In order for you to help a patient develop a payment plan for elective surgery you should
Review insurance coverage with patient.
What is double-booking?
Same appointment time is given to two or more patients
Modified Wave?
Scheduled the same as a wave but with the exception of scheduling patients in the last 30 minutes at 10-20 minute intervals.
Drugs & Dosages
Second 'D' in CHEDDAR means
How would you properly cancel an appointment if you are using a paper scheduling system?
Single line though the appointment.
What is a matrix?
Specified time periods being blocked out
S/R?
Suture Removal
Chronologic
The arrangement of events, dates, etc., in order of occurrence
Chief Complaint
The main reason for seeking medical care
Privacy Officer
The person designated by a healthcare organization, whether hospital system or private practice, who handles and oversees the maintenance of protected health information
Charting
The recording of observations, subjective and objective findings, diagnostic procedures, treatments and other pertinent data in the patient file
Purpose of medical records
To facilitate the provider's evaluation and manage the patient's course of treatment.
Single-booking?
a single patient is booked for a specific amount of time.
indexing
a system of cross-referencing information contained in office files so that the data may be searched using different characteristics as the query term.
example of how to answer a call
with a smile on your face; "Good morning, Central Medical Center, Ellen speaking, how may I help you?"
BiCaps
words or phrases with unusual capitalization
Intercaps
words or phrases with unusual capitalization
if a patient requests a prescription refill
you need to know the name and phone number of the pharmacy as well as the name of the medication, strength, and prescription number and when the prescription was last filled
BP
blood pressure check
inj
injection
type of call: prescription refills
route to clinical medical assistant
type of call: referrals
route to clinical medical assistant
types of appointments
1. Comprehensive Physical Exam 2. follow-up 3. immunization 4. new patient etc.
guidelines for handling the provider's telephone
1. answer the telephone as promptly as possible, with a smile 2. keep a pad and pen next to the telephone at all times 3. verify the caller's name and correct spelling 4. determine the reason for the call 5. handle as many calls as possible without disturbing the provider 6. if the provider prefers to speak to a patient, call the provider to the telephone after asking who is calling 7. if you cannot handle to call alone, take a message for the provider 8. make a memorandum for the provider of every call 9. always know where to reach the provider 10. if the provider cannot be reached, have the message by your phone 11. learn how much medical information the provider wishes you to give over the telephone 12. when answering a second line, determine whether it is an emergency or another provider before placing the line on hold 13. allow the caller to say goodbye and hang up first
key elements when recording a phone message to the patient's chart
1. caller's full name, spelled correctly, date of birth, M/F 2. a detailed and accurate message indicating the nature of the call 3. if requesting prescription, include name and phone number of pharmacy, drug name, dosage, last refill date 4. if requesting lab or test information (results), attach report to message 5. action required (attach to message or chart if available; if not, state so) 6. date, time of call, initials of person receiving call 7. phone number of caller - including area code if appropriate - and if OK to leave message (verify with CCP)
basic guidelines for handling several ringing lines
1. excuse yourself and ask the patient you are speaking w/ whether you may place him/her on hold 2. answer the second call, determining the nature of the call and asking whether he/she can hold 3. return to the first call and thank him/her for holding 4. resolve the first call and return to the second call
transferring telephone calls
1. give the caller the phone number, the extension, and the person's name to whom you are transferring him/her in case of disconnection 2. signal (or page) the person and, when the person answers, explain who is waiting to speak to him/her and give a brief summary of the issue 3. pull the chart for the provider if the patient is calling for information and have the pertinent data readily available 4. after the person picks up the line, you may give additional information as needed
common types of phone calls
1. patients who are calling for appointments, prescriptions, or the results of a test 2. referrals 3. emergency calls 4. other providers, hospitals or laboratories 5. personal calls and general business calls
when you have more than one line coming in to the office
1. place your first call on hold properly 2. find out who is on the second line 3. determine whether it is an emergency (or a hospital or doctor calling) 4. put the second caller through if an emergency, or on hold if not, while you finish the first call
when scheduling patients
1. positively identify the patient (use at least two identifiers: date of birth and first and last names) 2. confirm the last appointment date 3. make sure they are a current patient 4. assess type of appointment needed and note in the schedule
the average time for a person to pick up your attitude from listening to the tone of your voice
10 seconds
frequently called numbers
911, local hospital(s), ambulance/patient transport systems, lab services, IT department, pharmacies, insurance companies, referrals and authorizations department, provider specialists, home health, senior services, answering services, office manager, pager/cell phone for provider, quality department, HR department, office extensions
USPS Special Services
A certificate of mailing is used to prove that a document was mailed. No record is kept at the post office. It does not provide proof that the letter was received by the addressee. Certified mail provides a mailing receipt and a record of the mailing at the local post office. This service is available for First-Class and Priority Mail. Return receipts can be purchased in conjunction with this. Return receipts are used to prove that the recipient received the document. Registered mail provides the most protection for valuables. It is available only for Priority and First-Class mail. The maximum insurance that can be obtained is $25,000. This service can be combined with return receipts. International rates are available from your local post office. Type the address as discussed earlier, and type the name of the country on the last line without abbreviations. All physician's offices should have a supply of Express and Priority Mail envelopes along with a current fee schedule.
patient portal
A component of an Electronic Health Records (EHR) system that allows patients to communicate with their medical office electronically, to request lab results, referrals, appointments, and in some instances communicate with doctors via email.
Memorandum Development
A memorandum (often called a memo) is for communication within the office or with another department only; it is never sent to patients. It is less formal than a letter and is generally used for brief announcements.
Components of a Memorandum
A memorandum contains the standard elements in the following list 1. Heading The word memorandum is typed across the top of the page. 2. Date Use the same rules for letters when typing the date for memorandum. 3. To: List the names of all recipients in either alphabetical order hierarchy order. If the memorandum is going to a particular group, it can be addressed to that group. 4. From: List the name and title of the person sending the memorandum. 5. Subject Insert a brief phrase describing the purpose of the memorandum. 6. Body Write the message of the memorandum here. 7. Copy (c) Use the same rules as for letters when sending duplicate copies of memorandums. Salutations and closings are not use in memorandums. All lines in the memorandum are justified left, and 1 inch margins are used. Writing a memorandum entails the same steps (preparation, composition, editing) as writing a business letter. The memorandum should be read and initial by the physician before it is distributed. Your computer software will have a memorandum template.
fax
A message that is transmitted over phone lines and printed by the recipient's equipment.
Threshold
A minimum amount of supplies to be maintained, also known as par level
screening
A preliminary or indicating procedure.
triage
A system of sorting and identifying the severity of injuries.
Components of a Letter
A typical business letter has 11 components.
Abbreviations and Symbols
Abbreviations and symbols can save time in long handwriting and with typing. When you use abbreviations in medical documents, your reader must be able to recognize or translate the abbreviation. Abbreviations are not used as often as they once were. The possibility of confusion is not worth the time saved by using an abbreviation. When in doubt, spell it out.
CHEDDAR Charting (Chief complaint, History, Examination, Details, Drugs/Dosages, Assessment and Return Visit)
Acronym that provides a structured charting method for data acquired during a routine healthcare visit; It encourages more detailed of the information obtained during patient interview and examination
Corrections
After making corrections, print a final copy of the letter. Remember, a computer spell check should be used with caution because it highlights misspelled words but not incorrectly used words.
Sending Written Communication
After the document has been written, proofread, and signed, it is ready for you to send it to its receiver. Fold the letter in thirds, and place it in an envelope. Most professional letters are sent through the postal service. Other types of written communication are sent through fax machines or by email. Here are two key steps to remember when sending any type of written communication: • All attempts must be made to ensure patient confidentiality. The outside of envelopes should be marked confidential when the correspondence contains information about a patient. Send letters only to known or confirmed addresses. • Return addresses must be use so that mail can be returned if the recipient is no longer at the given address.
Editing
After you have composed the letter, edit it for both grammatical errors and factual information. Editing is a key step in making your letter a success. Editing entails two steps; proofreading and corrections.
Enclosure
An enclosure is something that is included with the letter. It is abbreviated Enc. and is placed two spaces down from the identification line. The number of documents included is placed in parentheses; if only one document is included, just the abbreviation Enc. is used.
Inventory
An itemized list of goods in stock
Biohazardous
Any material that has been in contact with body fluid and is potentially capable of transmitting diseases
Streaming?
Appointments scheduled for a particular amount of time based on patient needs.
Software
Computer programs necessary for directing the computer hardware to perform specific functions
etiquette
Conventional rules for correct behavior.
Confidential Communication Preference
CCP, A form that a patient signs that authorizes other individuals to receive information regarding the patients care.
Plural and Possessive
Converting words to plural or possessive form can be tricky. Most medical terms have a Latin or Greek origin and have their own set of rules for pluralization. You should be accurate because mistakes can cause confusion.
type of call: billing or insurance calls
route to clinical medical assistant (or provider)
Opening and Sorting Mail
Each physician will have an individual policy on which mail you should open and how you should process it. Any mail marked urgent should be handled first, followed by mail about patient-related issues. Promotional material should be handled last. Some physicians will have you sort, file, and respond to mail without their review. In some practices, however, all mail is place in a special file folder and handled only by the physician or office manager. Most physicians will open and handle their own mail. If the physician is on vacation, he or she will apply an auto reply response to his or her email address. When the physician is away, personal mail is placed on his or her desk and left for the physician to handle when they return. Mail that pertains to patient care issues should be opened and handled appropriately. Ask your supervisor if you are unsure which pieces of mail you should open. If the mail requires an urgent response, the covering physician should be contacted unless otherwise directed. Mail should never be allowed to accumulate inside mailboxes because patient information is confidential.
ECG (EKG)?
Electrocardiogram
Electronic Mail
Electronic mail, or email, allows computer to computer communications, weather within the same facility or anywhere throughout the world. The communication occurs through a modem. Each computer must be linked to an online service provider. Here are a few things you should remember about sending letters via electronic mail: • Confidentiality cannot be guarantee. • Follow the usual steps of prrparation, composition, and editing. • You can attached letters to an email by clicking on the file attachment icon, locating the letter, and inserting it. It is always a good idea to open the attachment to make sure that you are attaching the correct letter or version.
Facsimile Machines
Fax machines allow the medical office to send and receive printed material over a phone line. These machines offer a convenient and cost-effective way to transmit records, orders, prescriptions, test results, and other materials that require quick receipt. Always use a cover sheet when sending papers through a fax machine. At minimum, a cover sheet should have the following information: • Name, address, telephone number, and fax number of the physicians practice. • Name of the intended receiver of the fax. • Number of pages being sent, counting the cover sheet. • Telephone number of the fax machine of the intended recipient. • Date and time the fax was sent. • Confidentiality statement. When you receive a fax, forward it to the appropriate person. The fax machine should be checked regularly throughout the day, and all items should be sorted quickly. Sometimes when you fax a given letter, the fax machine may be busy, or the number dialed may be busy. If the number is busy, it is not acceptable to leave the fax paper in the machine for redial unless you are sure that no one else will have access to that document. Never leave documents unattended.
Details
First 'D' in CHEDDAR means
Basic Spelling Guidelines
Good spelling skills take time to acquire. Many words sound exactly alike but are spelled differently and have different meanings. Spell check in word processing programs can be a great asset, but they have limitations. Medical terminology spell check software should be added to your computer and be updated frequently. You can add medical terms into your computer's spell check dictionary, but make sure that any word you add is spelled correctly!s Spell checks can never be 100% stocked with all the needed terms, especially in the medical profession, as new technologies, medications, and treatments arise daily. Remember, spell check will not recognize words that are spelled correctly but misused. Even if you use spell check, you should proofread your document for other errors.
Guidelines for Producing Professional and Medical Documents
Good written communication skills are important for success. In the medical office, written communication is generated in several forms, such as reports and letters. Medical assistants commonly compose collection letters, patient reminders, and notifications of test results. You may also have an opportunity to produce memorandum, agendas, and minutes for meetings. Another important form of written communication is the hand written entry in a patient's medical record. No matter which form it takes, your written communication must be clear, concise, and correct. Poorly written documents reflect negatively on the physician's practice and on you. Written communication may be sent or receive through fax machines, electronic mail, delivery services, or U.S. postal service. HIPAA's privacy rule protects the confidentiality of all medical communication. Sending and receiving written communication according to the rules of confidentiality will be further discussed.
When patients arrive at the office, the administrative MA should:
Greet the patient, and explain all instructions thoroughly.
Numbers
In general, numbers 1 through 10 should be spelled out, except when used with units of measurement, and numbers over 10 may be expressed as a numeral. When several numbers are used in a sentence, this rule is ignored in order to maintain consistency. All numbers in a sentence should be written in the same form.
Lab information
In general, the Medical Assistant is the first person to inspect reports but the provider will discuss any abnormal results
What are three consequences that could arise from inaccurate information in a business letter?
Inaccurate information in a business letter can lead to injuries to the patient and lawsuits and can harm the physician's practice.
Subjective and Objective
Information classified two ways
Correspondence and referrals
Informational or request-for-information letters from insurance companies
Inj.?
Injection
Audit
Inspection
What is a referral?
Insurance company requirement, before they pay for a specialist.
If your phone tone is high pitched combined with drawn-out speed
It translates as "I don't believe what I'm hearing"
If your phone tone is an abrupt speed and loud tone
It translates as "I'm angry and not open to input"
If your phone tone is monotone (a flat voice)
It translates as "I'm bored and have absolutely no interest in what you're talking about"
If your phone tone is slow speed and low pitch
It translates as "I'm depressed and want to be left alone"
If your phone tone is a high-pitched and empathic voice
It translates as "I'm enthusiastic about this subject"
USPS Mailing Options
Mail can be sent in a variety of ways based on its urgency and value. The following is a brief description of the services offered by the USPS: • Express Mail, the fastest service, ensures delivery of your package by the next day. Express Mail is delivered 7 days a week. Express Mail is automatically insured for $500. Additional insurance is available. • Priority Mail, the second fastest service, offers 2-day delivery to most destinations. The maximum weight is 70 pounds, and the maximum size is 108 inches combined length and girth. The rate is based on the weight of the package. You can purchase up to $5,000 of insurance for packages. • First-Class Mail is the service used for sending standard mail (letters and postcards) weighing up to 13 ounces. Mail weighing more than 13 ounces will be considered Priority Mail. • Standard Mail (A) is used by companies to mail books and catalogs. Standard Mail (B) is used to mail packages weighing more than one pound. The maximum weight is 70 pounds, and the maximum measurement is 130 inches combined length and girth. • Postal rates, fees, and services are subject to change. You must stay abreast of the latest information. Use the USPS website for additional information and updates.
Accuracy
Many of the medical documents or letters that you will write contain information that requires precision, accuracy, and careful attention to details. Inaccurate information in some letters can lead to injury of a patient and lawsuits and can harm the physician's practice. some of your letters will be placed in the patient's permanent medical record. Most letters will start with the physician asking you to draft a letter. He or she may or may not give you some notes to follow. He or she may dictate the letter. Either way, your responsibility in typing the letter is to be as accurate as possible and to question anything about which you are unsure.
conference calls
used to simultaneously conduct conversations with several people in various locations at the same time
Other Delivery Options
Many other companies specialize in document and package delivery, particularly with next day or second day delivery services. Examples of these companies include Airborne Express, Federal Express (FedEx), and United Parcel Services (UPS). Use the company with which the physician has an account. Fees vary, so you may have to contact each company for prices and available services. These companies offer services such as tracking, pick-up services, money back guarantees, and proof of delivery. The tracking service can be done through their website.
Types of Incoming Mail
Many types of mail are receive daily in the physician's office. • Advertisements • Bill for office services • Consultation letters • Hospital communications and newsletters • Laboratory and radiographic reports • Office supply magazines • Patient correspondences • Payments from insurance companies and patients • Professional journals • Literature from professional organizations • Samples (drugs, laboratory test kits) • Waiting room magazines
What are memorandums used for?
Memorandums are used for communication within the office and with other departments.
NS?
No Show
P & P
Pap. and Pelvic
Receiving and Handling Incoming Mail
Part of the daily routine for a medical assistant is handling the incoming mail. Sort the mail quickly and promptly to ensure efficient functioning of the office.
Instead of saying "When would you like to come in?"
Say "Do you prefer mornings or afternoons?"
Instead of saying "What is the problem?"
Say "What is the reason for the visit?"
Instead of saying "Are you a patient here?"
Say "When did we last see you?"
Punctuation
Period (.) - used at the end of sentences and following some abbreviations Comma (,) - used to separate words or phrases that are part of a series of three or more. The final comma before "and" may be omitted. A comma can also be used after a long introductory clause or to separate independent clauses joined by and, but, yet, or, and nor. Semicolon (;) - used to separate a long list of items in a series and to separate independent clauses not joined by a conjunction. Colon (:) - use to introduce a series of items, to follow formal salutations, and to separate hours from minutes indicating time. Apostrophe (') - use to denote emissions of letters and to denote the possessive case of nouns. Quotation marks (" ") - used to set off spoken dialogue, some titles, and words used in a special way. Parentheses [( )] - use to indicate a part of a sentence that is not part of the main sentence but is essential for the meaning of the sentence. Also use to enclose a number, for confirmation, that is spelled out in a sentence. Ellipsis (...) - used in place of a period to indicate a prolonged continuation of a conversation or list. Also used to display individual items or to connect phrases that are loosely connected. Diagonal (/) - used in abbreviations, dates, fractions, and to indicate two or more options.
PT?
Physical Therapy
Assault
Physical harm; a violent attack
Professional Letter Development
Professional writing is different from writing letters to your friends or family members. The goal of professional writing is to get information communicated in a concise, accurate, and comprehensible manner. Slang or idiomatic terms that are commonly used in writing letters to friends are not appropriate for business letters. Writing effective business letters is a skill that requires practice and careful attention to detail. To write a professional business letter, you must: • Understand the components of a letter. • Use the correct letter format. • Ensure that the message is clear, concise, and accurate.
Basic Grammar and Punctuation Guidelines
Professional writing requires that you follow the appropriate rules of grammar and punctuation.
What is the purpose of proofreading?
Proofreading allows you to check the accuracy and content of the letter.
Affixing Postage
Proper postage must be affixed to the envelope buy a stamp, permit imprint, or a postage meter machine. Postage meter machines are in-house machines that are regulated by the USPS. They contain a prepaid amount of postage and can imprint the postage stamp either directly on the envelope or onto an adhesive tape that is applied to the envelope. Some machines weigh, stuff, and seal the envelope. The date on the postage machine must be change daily, and the ink roller must be kept full. The physician may opt to use the USPS permit imprint program. In this case, you take the mail, sealed and ready to be sent, to the post office. The postal clerk passes the letters through the USPS machine, and a permit stamp is placed on the envelope. The postal clerk deducts the postage charges from your prepaid account. The advantages to this system are that it saves time and does not require the office to care for the postal meter machine.
Re?
Re Check
Insurance companies typically require patients to obtain what before hey pay for a visit to a specialist?
Referral
Electronic Health Records (EHR)
Refers to the interoperability of electronic medical records, or the ability to share medical records with other health care facilities
Be Careful What You Report in the Minutes
Remember, you are recording the happenings of a meeting that will stay on record for years. The minutes of a meeting should not include personal opinions or any information that is not relevant to the business of the group. The purpose of minutes is to record the actions that took place at the meeting.
expressed
Said or made known in words or by action.
third ring
when a phone should (at least) be answered by
Sig?
Sigmoidoscopy
Annotation
Some physicians request that letters be annotated. Annotation involves reading a document and highlighting the key points. If the letter is very detailed, a summary of the key points should be written in the margins. The summary should be factual and not editorialized.
Surg?
Surgery
empathy
Sympathy for or identification with another's emotions.
What does an Pptical Character Reader do?
The USPS uses Optical Character Readers to quickly and efficiently sort the mail electronically.
Copy
The abbreviation c: is used to indicate that a duplicate letter has been sent. It is typed two spaces below the enclosure line. Usually, letters are copied to managers, supervisors, or to the physician who requested that the given information be dispersed.
Body of the Letter
The body of the letter contains the message. It should be single-spaced with double spacing between the paragraphs.
Closing
The closing concludes the letter. Some common closings are Sincerely, Yours truly, Regards, Respectfully, and Cordially yours. Only the first word is capitalized, and a comma follows the phrase. Closing are placed two spaces down from the end of the letter. Never put the closing alone on a page.
Date
The date includes the month, day, and year. It should be position two to four spaces below the letterhead. The date must be typed on only one line, and abbreviations should not be used.
Continuity of Care
The delivery of services provided to a person that proceeds without a lapse or interruption, with the intended purpose of maintaining a level of health and treatment.
Composition
The goal of composition is to ensure that your message is transmitted clearly, concisely, and accurately to your reader. As you did during preparation, focus on the message, not on the mechanics. A clear message ensures that your reader knows precisely what is expected, an unclear message leaves room for doubt. A concise message is short and to the point. Wordy phrases with many adjectives should not be used. An accurate message includes the correct date, time, figures, and information. Inaccurate messages cause delays and confusion and can lead to poor public relations.
Identification Line
The identification line, an optional component, indicates who dictated the letter and who wrote it. It consists of abbreviations only. The initials of the person who dictated the letter are capitalized (generally the physician); the initials of the writer of the letter are in lowercase (generally these will be yours). The identification line can also be called the reference line.
personality
The individual qualities that make one person different from another.
Whose address is typed as the inside address? What is the purpose of the salutation? What is the purpose of the identification line?
The inside address is the address of the person to whom the letter is going. The salutation is the greeting. The identification line shows the initials of the person who dictated the letter and the initials of the person who typed the letter.
Inside Address
The inside address refers to the name and address of the person to whom the letter is being sent. A 9-digit zip code should be used if available. The inside address is placed two spaces down from the date unless the letter is being mailed with a window envelope and it will not be aligned correctly. Never abbreviate city or town names. States can be abbreviated.
Letterhead
The letterhead consist of the name of the practice or physician, address, telephone number, fax number, and sometimes the company logo. The letterhead is oftrn embossed in color and centered on the top of the page. The letterhead may also be preset into a template.
Minutes
The minutes of a meeting outline the actions of the group. Members may need to refer back to the minutes of a previous meeting. In organizations with officers, the secretary takes notes and/or records the meeting. For other meetings such as committee or board meetings, someone is assigned the task of preparing the minutes. You should type the minutes of a meeting as soon as possible. Record only motions, seconds, and the results of a vote. You may include a brief discussion of the motions, but do not include unrelated items, opinions, or individual members' statements. The minutes of a meeting become an important document in the association's history. Include the following information: • List of members present. • List of members absent. • Date and time the meeting was called to order. • Statement regarding the acceptance of the previous minutes. • Motions made and the name of the person making the motion. • Brief report of discussion. • Results of voting, whether the motion passed or not. • List of reports that are submitted. • Date and time of the next meeting. • Adjournment time. • Signature of the person who prepared the minutes and the Chairman's signature.
Signature and Typed Name
The name of the person sending the document is typed four spaces below the closing, with the person's title typed directly below. The physician will read and sign the letter above the typed name. If you are instructed to sign the letter, sign the physician's name followed by a slash mark with your name. Example: Susan James, MD / Reyna Smith, CCMA
Agendas
The purpose of an agenda is to outline briefly but topics to be discussed at a meeting. It allows the meeting participants to prepare any necessary reports before the meeting and to anticipate questions. Agendas usually begin with a call to order, followed by a review of previous meeting minutes, old business updates, and then new business. Adjournment is the last item on the agenda. The format and amount of detail included in an agenda is determined by the type of group that is meeting.
Salutation
The salutation is the greeting of the letter. It is placed two spaces down from the inside address or the subject line. Capitalize the first letter of each word in the phrase, and end the phrase with a colon. It is permissible to eliminate the saltation if the letter is formal or if a subject line has been used. When writing to a physician, write out the word doctor.
Addressing Envelopes
The standard business envelope is no. 10. USPS regulations state that the minimum size of an envelope is 3 1/2 by 5 inches. It must be rectangular and no less than 0.007 inches thick. The standard no. 10 business envelope is 4 1/8 by 9 1/2 inches. The requirements for addressing an envelope are necessary because the Postal Service uses Optical Character Reader, which quickly and efficiently sorts the mail. As the mail travels through the scanning devices, it is sorted electronically. The return address is placed in the upper left hand corner. It should not exceed 5 lines. The return address is typed with the same guidelines as for letters and is single spaced. Often, medical offices have the return address preprinted on the envelope. The recipient's address is typed 12 spaces down from the top and centered on the face of the envelope. All words of the address should be capitalized. Only postal abbreviations for States should be used, and no punctuation is used between the postal abbreviation and the zip code. All addresses must include the 5-digit zip code whenever possible, the 4-digit expanded zip code should also be used. The expanded zip code allows the USPS to sort and route mail faster and more accurately. Envelopes should not be handwritten, as this does not portray a professional image. The entire address should not exceed five lines. Your software may allow you to insert a USPS PostNet ba rcode. This is generally inserted two to three lines below the address. This bar code accelerates USPS sorting. Always check your software to make sure it is certified by the USPS.
Subject Line
The subject line, an optional component, is used to state the intent of a letter or to indicate what the letter is regarding. It is placed on the third line below the inside address and is written as Re:
Hardware
The visible parts of computer system (keyboard, disk drive, monitor, and printers)
Letter Formats
There are three basic types of letter formats: full block, semiblock, and block. Office policy or the physician preferences will dictate which format you use.
Why should all numbers in a sentence be written in the same way regardless of the rule?
This practice ensures consistency, a mark of professional writing.
Ergonomic
To applied science of being concerned with nature and characteristics of people as they relate to design and activities with the intention of producing more effective results and greater safety
Composing a Business Letter
To create a professional business letter, follow these three steps: preparation, composition, and editing.
anticipate
To predict, based on experience and training, situations or events that may be likely to occur, that may or may not require intervention.
Composing Agendas and Minutes
Two other forms of written communication are agendas and minutes.
confirmed
Verification of authenticity.
Proofreading
Whenever possible, have a colleague proof read your letter and provide constructive criticism. Be sure to maintain confidentiality. If you are using a computer, consider printing out a hard copy of your document for proofreading, some individuals find it difficult to proof read a document on the computer screen. Checking for the following items: • Accuracy of all information • Clarity and conciseness • Grammar • Spelling • Punctuation • Paragraph appropriate in length and limited to one subject • Capitalization • Logical organization and flow. Use proofreader's marks to speed up the editing process. These are standard marks used to indicate corrections. You should become familiar with these basic marks.
Meaningful Use
With reference to healthcare records, this terms is used by government agencies to refer to the way in which medical record information is employed in order to provide a means for improving patient care and patient outcomes through evaluating treatment patterns and verifying necessity of medical procedures performed
Transcription
Writing over one book or medium into another; typing in full in ordinary letters
United States Postal Service
Written communication is commonly sent via United States Postal Service. Envelopes must be correctly prepared so that the Optical Character Reader used by the USPS can sort the mail quickly and efficiently. The OCR reads the envelope, scanning for information. The OCR scans all envelopes using these margins: 1/2 inch on either side and 5/8 inch from the top or bottom of the envelope. Addresses or notations outside of these margins will not be read.
Types of Business Letters
You will be asked create an type various letters. Letters that you write will be sent to patients, insurance companies, other healthcare providers, pharmaceutical company, and various businesses. here are some common type of letters that you may write: • Letters welcoming new patients to the practice. • Letters to patients regarding their test results. • Consultation reports to other healthcare professionals. • Workers' Compensation letters verifying the patient's injury or treatment. • Justification or explanation of treatments to insurance companies. • Cover letters for transferring patients' records to another practice. • Clarification or explanation to patients regarding fees or billing concerns. • Thank you letters to sales representatives. • Physician changes for on-call schedules (generally sent to the hospital and covering physicians) • Announcements of new services, hours, or office location changes
Margin
a blank space around the edges of a piece of paper, such as a letter or page of a book
Agenda
a brief outline of the topics to be discussed at a meeting
matrix
a format for establishing a time schedule for appointments.
teleconferencing
a means of exchanging information, where everyone can see and hear each other at the same time
Template
a skeleton of a letter or document with preset and prespaced elements
Full Block
a type of letter format in which all letter components are justified left
Block
a type of letter format in which the date, subject line, closing, and signature are justified to the right margin; all other lines are justified left
Semiblock
a type of letter format that is styled the same as block, except the first sentence of each paragraph is indented five spaces
Memorandum
a type of written documentation used for interoffice communication
Font
a typeface; affects the way written messages look
validation
all lab reports, test, consult reports and outside testing received should go to the provider for review and signoff first
finishing the conversation
allow the caller to hang up first; say "Goodbye" or "Goodbye, Mrs.Jones"
Salutation
an introductory phrase that greets the reader of a letter
answering the telephone
answer each call as soon as possible
if you do not have a response within the original time quoted
call the patient back and let him/her know you are still waiting and will call back as soon as you have the information
business and legal calls
common practice is for them to be referred to the office manager
Hazards
dangers, risks
booking appointments
determine which patients need to be seen in the same-day and urgent time slots; book any open appointments in order during the day
professional etiquette
dictates that the provider will not keep a colleague waiting unless the provider is involved with an emergency or surgical procedure
information from the telephone screening
document it in detail and attach/relay a message for the doctor to review
if a caller makes any threats
document the identity of the caller, the nature of the threat, advise you are no longer the person who can help, and inform your supervisor; end the call in a professional manner; document the details of the call and if deemed appropriate, contact the police department; complete the Unusual Occurrence Report
if the patient ask to speak with the provider
say "The doctor is with a patient now. May I take a message and we will return the call as soon as possible?"
if the caller would be on hold for more than one minute
don't put them on hold, but say "May I call you back with the information?" and check the patient's phone number before hanging up
if the person on the phone needs additional information or if the call is going to take a while
excuse yourself from the phone call by saying "May I put you on hold for a moment?"
if the caller is cursing
give the caller the benefit of the doubt and politely say "I really want to help you, but I'm having trouble with the kind of language you are using. can you please refrain from using that kind of language?"; give the caller a second chance and another warning if the language persists; if this does not work, let the caller know that you are no longer the person who can help them and inform your supervisor of the problem
information to and for the caller
his/her name, all information needed (and repeat it back); let the caller know when he/she may expect a response
difficult callers
hold off any negative judgments and try your best to accommodate the requests
type of call: another provider
immediately route to provider
type of call: hospital calling for orders
immediately route to provider
type of call: patient requesting medical advice
immediately route to provider (usually set up patient appointment)
type of call: third party request for information about a patient (if not billing or provider referral related, check CCP for authorization to release)
immediately route to provider; route to administrative medical assistant (check CCP)
type of call: any situation deemed to be an emergency by the provider
immediately route to the provider
type of call: patient requested test results (attach results to message)
immediately route to the provider (if abnormal results); route to clinical medical assistant (if results are normal and protocol approved by provider)
Enclosure
indication for the reader that an item is accompanying the letter
information that can be given to another party
information that has been authorized by the patient in writing, with the patient signature
Capitalization
it is important to know when to capitalize and when to use lowercase letters. Following standard guidelines for using capital letters applies to most correspondence, but there are some exceptions and additional rules when typing medical documents. Never change how a word is capitalized unless directed to do so. Ask for clarification and mark the proof letter with a ? for the physician to assist. • Capitalize the first word in a sentence, proper nouns, the pronoun "I", book titles, and known geographical names. • Names of persons, holidays, and trademark items should be capitalized. • Expressions of time should not be capitalized.
LAB
labratory studies
data regarding patients
may not be given out over the telephone to anyone unless the patient has given written permission fro the release of specific information with a signature
all messages
must be signed off (both paper and electronic) to confirm that final action has been taken
messages from the answering service
need to be returned in the order of importance within an appropriate and reasonable time period
upon completion of refilling a prescription
notify the patient that the prescription has been sent to the pharmacy so that that the patient may pick up the medication
automated system
often provides information such as the provider's profiles, prescription refill policies, office hours, emergency contact information, and hold times
reminder calls
placed to patients 24-48 hours before the appointment
calls from attorneys
pull the patient chart and look for authorization listing the name of the patient and the signature of the patient
confirming appointments
reading the scheduled time back to the patient after it has been recorded in the appointment book or scheduling system
type of call: patient complaints
record message for the provider (and to supervisor and quality department)
type of call: critical lab results
record the results then route immediately to the provider
if there is a serious telephone emergency that cannot be handled in the facility
refer the patient to an emergency medical service and explain that it will send someone as soon as possible to help (ex. the nearest hospital)
type of call: scheduling appointment
route to administrative medical assistant
if you are speaking with a patient face to face and must answer the phone
say to the patient "Excuse me for a moment, please", answer the phone call, and then continue with what you were doing
patients who phone for appointments
should be given a choice of two appointment times
screening manual (triage manual)
should be kept near each phone for reference so that each person who answer the phone will ask standard questions and give the standard response as has been pre-authorized by the provider
urgent messages
should be marked urgent and given to the doctor immediately
general rule for prescription refills
the medical assistant does not give out information or call in a prescription without the express direction of the provider
Proofread
the part of editing a document in which the writer reads the draft for accuracy and clarity and corrects errors
Annotation
the process of reading, highlighting, and summarizing a document for another person
Sentence Structure
• Avoid long, run-on sentences • A verb must always agree with its subject in number and person. • Ensure the proper pronoun (he or she) is used. • Adjectives should be used when they add an important message. Don't over use adjectives or adverbs. Remember, double negatives use in one sentence make the sentence positive.
