Medical Writing and Proofreading Techniques

Communication

• Communication is the exchange of information, thoughts, or messages through signals, speech, writing, or behavior.
• Correspondence includes written forms like notes, interoffice communication, emails, patient charts, letters, and business/personal letters.

Written Communication Uses

• Informing staff about policies or decisions
• Informing patients/customers about policies or decisions
• Contacting professional colleagues
• Corresponding with professional associations
• Responding to or requesting medical consultations
• Engaging in business communication with suppliers, consultants, attorneys, or insurance companies
• Sending messages regarding a patient
• Sending personal messages

Medical Records and Documentation

• All documentation is part of the legal medical record.
• Written communication reflects professionalism.
• Most documentation is now electronic.

Interoffice Communication

• Informal, memo-style communication.
• Focuses on specific concerns.
• Distributed electronically or by memo to ensure awareness of events, policies, and internal communications.

Informal Notes

• Personal, first-name correspondence.
• Used to express thanks, congratulations, or similar sentiments.

Professional Letters

• Providers may need to communicate with associations, licensing boards, and physicians regarding medical issues affecting practice.
• Providers may request assistance from medical assistants to write letters with the provider's signature regarding tasks such as travel agencies, mail-order catalogs, uniform suppliers.

Electronic Mail (Email) Pros

• Enables communication with many people simultaneously.
• Creates a record of the communication.
• Facilitates easy information retrieval for correspondence
• Is fast, accessible, and saves time when you need to communicate.
• Enables attachment files without delay.
• Environmentally friendly.

Electronic Mail (Email) Cons

• Not best for highly charged issues.
• Can be overused as a substitute for meetings
• Not as secure as other forms of communication.
• Can be used as evidence in court, increasing liability risk.
• Can be a problem for time-sensitive issues.
• Less personal and can be misunderstood.
• Can result in email overload, leading to information overload.
• Potential for virus transmission.

Email and Computer Viruses

• Increased internet dependence raises threat of computer viruses.
• Viruses can interfere with or destroy electronic files.

Form Letters

• Useful for return-to-work/school approvals, annual physical/examination reminders, delinquent account reminders, missed appointments, and dismissals from practice.
  • Office visit verifications (for work or school absence).
  • Athletic participation approvals.
  • Information for referred patients (appointment confirmation, location, prep information).

Information Sheets

• Patient education.
• Specific written instructions regarding examinations and diagnostic tests performed in the office.
• Reinforcement of office explanations.
• Reminder to patients after leaving.
• Excellent patient education material.

Ownership and Intellectual Property

• Internal emails are owned by the company that provides the email system.
• Do not copy or forward confidential company files or information. Avoid email or forwarding of patient information without consent.

General Writing Guidelines

• Sentences should be appropriate lengths to match the material. Business letters require concise materials.
• Avoid run-on sentences.
• Use complete thoughts.
• Capitalize names, holidays, and major work titles.
• Use numbers consistently.
• If a number is under 10, it is spelled out.

Proofreading

• Proofreading is careful reading to correct errors
• Watch for combinations of punctuation, words ending in “s”, capital letters, numbers, apostrophes, hyphens, dashes, periods, and commas, two-letter words, repeated letters.

Letter Styles

• Full block style - alignment of all elements of the letter to the left.
• Modified block style - the date, closing, and signature aligned to the right of the center. Addressing Envelopes
• Use a standard font
• Order of information: post office city, state, and ZIP code or ZIP + 4.

Preparing Mailings

• Address envelopes correctly.
• Use optical character readers (OCRs).
• Ensure the correct address, to aid in accurate reading and efficient delivery.
• Ensure use of appropriate fonts to meet standards that OCR systems utilize..