Notes on Communication PDF

`Notes Communication is the way we interact with others, it is the way we exchange information, thoughts, or messages by signals, speech, writing, or behavior. Correspondence, also known as written communication, includes sending and receiving notes, interoffice communication, emails, information r...

`Notes Communication is the way we interact with others, it is the way we exchange information, thoughts, or messages by signals, speech, writing, or behavior. Correspondence, also known as written communication, includes sending and receiving notes, interoffice communication, emails, information recorded in the patient's chart, form letters, information sheets, and business, professional, and personal letters. Written communication is used. ​ To inform the staff officially of a policy or decision ​ To inform pts or customers of a policy or decision …​ ​ To contact professional colleagues ​ To correspond with professional associations ​ To respond to or request a medical consultation ​ To engage in business communication with medical suppliers, financial consultants attorneys, and insurance companies ​ To send a message regarding a patient ​ To send personal messages First, any documentation is part of the legal medical record. Second, your written communications reflect directly on your level of professionalism. In today’s healthcare setting, most documentation is done in the electronic format: Interoffice communication (IOC) is informal, memo-style communication focused on specific concerns. It is circulated electronically or by memo to ensure everyone is aware of events, policies, and internal communication. Informal notes are personal, first-name correspondence used to express thanks, congratulations, or similar sentiments, often written on a first-name basis. Providers may request assistance with personal correspondence, such as with travel agencies, mail-order catalogs, uniform suppliers, and specialty shops. Medical assistants should be able to write the necessary letter with the provider's signature. Professional letters- Providers may need to communicate with professional associations, licensing boards, and physicians about issues affecting their medical activities or practice. They may also be involved in medical societies, hospital medical boards, research, or journal articles, requiring detailed dictation and perfect transcription. -​ The majority of correspondence, excluding patient charts, is business-related, including referrals, consultations, annual examination reminders, collection letters, school and work releases, equipment suppliers, and office operation correspondence. Form letters are especially well suited for: ​ Return-to-work or school approvals (following surgery or illness). ​ Annual physical examination reminders (e.g., CPE, eye examination, Pap test, mammogram, sigmoidoscopy). ​ Delinquent account reminders, usually in about three increasing levels of request intensity. ​ Noncompliance, missed appointments, and dismissal from practice. ​ Office visit verifications (for work or school absence). ​ Athletic participation approvals. ​ Information to referred patients such as appointment confirmation, office location, information needed, and examination preparation. Prewritten form letters can be stored electronically on computers, retrieved when needed, and printed. The master of each hard-copy form letter is stored electronically, and copies can be made or printed as needed. It's crucial to check patient charts for signed forms and ensure information is sent appropriately.] -​ A template is an electronic file (or preprinted document) with a predesigned, customized format. Information Sheets (Patient Education) Information sheets, or patient education, provide specific written instructions regarding the examinations and diagnostic tests performed in your office. They help reinforce what you have explained and serve as a reminder after the patient leaves the office. Information sheets can be prepared and stored in the files to be used as needed and are an excellent example of patient education material. They also typically explain to patients how to prepare themselves for a particular test or what to expect when the test is performed.  Email Email allows for the almost instant exchange of information. -​ In addition, the advantage of transmitting written material makes it appropriate for transferring reports, documents, correspondence, and most forms of written communication. To comply with patient privacy and Health Insurance Portability and Accountability Act (HIPAA) guidelines, all electronic communications, including email, must provide security measures such as restricted user access, encryption, and passwords. PROS CONS It enables communication with many people by sending the It is not the best medium for communicating certain same email to multiple recipients simultaneously. emotional or highly charged issues. It leaves a trail, so the history of a conversation can be It is often overused as a substitute for phone and traced. in-person communication. It provides an easy reference to past communications. It is not as secure, private, and confidential as people think. It does not require customers (patients) to be available to It can be used in a court of law as evidence and increases send them a message. company liability risk. It is fast, accessible, and saves time when you need to It can be problematic when dealing with time-sensitive communicate but do not have time for small talk. issues that require immediate responses. It enables you to attach pertinent files without the delay ofIt is less personal and can be misunderstood. other mail delivery systems. It is environmentally friendly, reducing the amount of paper The volume of emails received can result in information used, costs, and energy required to deliver mail. overload. A virus can be transmitted through email. It requires an established etiquette that helps ensure that good manners are the rule rather than the exception in cyberspace: ​ Emoticons are icons that express emotions, such as ☺ or ☺, but should not be used in a professional setting. ​ Abbreviations such as FYI, FAQ, and BTW are popular in email but should be used sparingly in the professional setting. ​ Avoid text messages–style writing. ​ Do not overuse cc. ​ Always review your email before sending it. Respect readers’ time by keeping messages clear and concise, but be sure to provide enough information for readers to understand what is being said or requested. Good emails are to the point but not so short that they create the impression of being rudely curt.  -​ Ownership and intellectual property: Whose email is it? The Electronic Communications Privacy Act ruled that internal emails are the property of the company that pays for the email system, thereby giving the company the right to search your mailbox. Do not copy or forward company policy, procedural files, or information owned by the organization. ​ Privacy: Emails can be sent or forwarded by accident or without knowledge or permission. ​ Do not copy or forward information owned by the organization; especially be mindful of never emailing a patient’s information without the express written consent of the party and verification of the recipient. ​ Legal considerations: Emails can be recovered (even deleted ones) and used for evidence in civil and criminal court cases. Demonstrate professionalism when sending any written correspondence, both on paper and in an EHR. Remember that you are documenting a legal medical record and that a digital footprint exists for every access and entry in a patient’s electronic chart. Email and Computer Viruses Increased internet dependence raises the threat of computer viruses, which can interfere with electronic files, especially with email use. A virus is information sent electronically to interfere with or destroy your electronic files. To keep your computer virus-free, follow these rules: examine emails' subject and sender, delete suspicious emails immediately, and never open executable or script files unless expected. Use antivirus software to scan emails before opening them, but keep in mind that new viruses are constantly being created and deployed, making it less effective than using the most up-to-date software. Patients are requested to sign these forms permitting for providers to communicate personal information. Some instances would be: ​ Patient personal use. ​ Life insurance questionnaire. ​ Disability insurance questionnaire. A release form is not required when releasing information about the patient’s care. Some examples of these instances would be: ​ To request a consultation from a specialist. ​ To provide results to the referring physician from a specialist. ​ To provide information to a hospital or nursing care facility. ​ To an insurance company for payment of services. The patient is provided with a written statement from the practice that explains its adherence to the HIPAA regulations regarding their personal information. Patients are asked to sign a form indicating that they have received a copy (or been provided a copy to read) of this document. This is often referred to as a Notice of Privacy Practices (NPP). HIPAA compliance and patient information privacy are crucial, requiring procedures like encryption, firewall software, personnel passwords, access restrictions, and activity logs to protect electronic applications with patient information -​ Office access to patient records is restricted to authorized personnel, limiting communication and preventing others from accessing patient information as per HIPAA regulations. Proper grammar, punctuation, and neatness are essential for effective communication. Avoid misspelled words, space properly, and avoid using the same major word twice. Utilize resources like books and the web for error-free writing. You must check any word whose accuracy you are not sure of. -​ Do not rely solely on the spell check feature because it is possible for the word to be spelled correctly but also to be a word out of context. Here are some ideas that might help you become a more accurate speller: ​ If you cannot recall how to spell certain words correctly, try making an alphabetical list of them to use as a quick reference. ​ Make a mental picture of the word correctly spelled. ​ Pronounce the word correctly several times. ​ Write the word, dividing it into syllables and inserting accent marks. ​ Write or type the word several times. ​ Learn to use general and medical dictionaries when you are in doubt. When writing letters, you must write in complete thoughts. A simple sentence consists of only one complete thought, that is, one independent clause with a subject and a verb. A compound sentence contains two or more independent clauses, separated by a comma. A complex sentence contains one independent clause and one or more dependent clauses. A dependent clause cannot stand alone as a sentence. A compound-complex sentence contains two or more independent clauses plus one or more dependent clauses. Written material should be composed of sentences of differing lengths and complexity to match appropriately the written matter being prepared. Patient referrals or business letters require concise material, whereas personal correspondence or medical articles can contain more variety. In any correspondence, avoid run-on sentences or any sentence containing too many clauses. To make sentences easier to read and to tell a reader when you come to the end of a thought, a variety of marks called punctuation are used. Capitalize names of persons and places, the first word in a sentence, names of holidays, principal words in titles of major works, and any product or title that might be trademarked. Medications are usually trademarked. The use of numbers must be consistent. If you use a specific reference style book (such as The Chicago Manual of Style), follow its instructions for using numerals or spelling out the numbers. Follow the rules your employer wishes to be used for your office. In the absence of other references and if the provider’s preference is unknown, usually, any number under 10 is spelled out, whereas those 10 and above are expressed in numeric form. A partially contradicting general rule says to spell out the number if it can be done in one or two words. A number at the beginning of a sentence must be spelled out. A person’s age and the time of day are usually written in figures. Dates, street numbers, and page numbers are written in figures. When several numbers are mentioned within a short space, figures should be used for all of them. Proofreading is a process of carefully reading printed material (or digitally displayed) and marking errors for correction. Watch for certain problematic issues in writing, such as: ​ Words ending in “s” ​ Combinations of punctuation ​ Capital letters ​ Numbers ​ Apostrophes, hyphens, and dashes ​ Periods and commas ​ Two-letter words ​ Double letters in words Career proofreaders use at least a three-read system. First, they read through the material to make sure it makes sense and to check for errors in composition such as a misaligned margin, paragraph indents, spacing on the page, and so on. Then they read for content, to make certain correct words, punctuation, and grammar is used. Last, they do a check of spelling. Going through these steps should ensure error-free communication. -​ Be certain to make a copy of every business letter or report sent from the office. Copies of correspondence regarding patients must be filed (or scanned/saved) in their charts. LETTER STYLES Letter styles vary in the location of some of the parts. In full block style, the dateline, address, salutation, body of the letter, complimentary close, typed signature, and the initials of the typist are flush with the left margin. This is a popular style because no tab stops are needed. Another popular style is the modified block with the dateline, complimentary close, and typed signature beginning a bit right of center. This style is compatible with most letterheads. The dateline sets the style. If you place the date at the right, you must follow with modified block style, lining up the complimentary close and typing the signature with the date. The least popular of the three styles customarily used in the medical office is the modified block with indented paragraphs. The type and quality of stationery make a statement about the provider’s office. -​ Letterhead stationery and matching envelopes are usually 16-, 20-, or 24-pound weight. The larger the number, the heavier the paper. It is usually ordered by the ream, which consists of 500 sheets of paper. -​ Continuation pages are plain bonds and should match the weight, texture, and brightness of the letterhead. A watermark appears on bond paper and should read across the paper in the same direction as the typing. -​ You can determine the correct watermark side by holding the paper to light. Composing the Letter Steps in the process to produce a final copy without errors are to: ​ Determine what information must be included (a) to answer a letter, (b) to respond to a verbal request, (c) to request information, and (d) to obtain a specific response. ​ 1.​ Determine the style for the letter and set margins for appropriate placement on the page. 2.​ Select the typeface and font size. 3.​ Compose a rough draft, using concise, easy-to-understand sentences. Use the words I and we as infrequently as possible, especially to begin sentences. Remember that it is awkward to use the same word twice in one sentence or even in consecutive sentences. Use a thesaurus to increase the variation of words to make the content more interesting. When using Microsoft Word to create letters, you can place your cursor over a word and right-click. In the pop-up box, scroll up to Synonyms, and alternate word suggestions are displayed. 4.​ Proofread the draft and edit the content. Eliminate redundant (extra, unnecessary) phrases. 5.​ Compose the final copy and prepare the envelope. 6.​ Sign it or give it to the sender to sign. 7.​ You can prepare a letter from dictated notes (dictation machine [tape], smartphone app), or you can compose it on the keyboard of your computer. Certain formatting standards must be considered when preparing a letter. The following are points to remember as you perform Procedure 20–1: 8.​ The date typed indicates when the content of the letter was dictated. 9.​ The month is spelled out in full. (Traditional style is month/day/year; military style is day/month/year.) 10.​ The inside address should be copied from the correspondence to be answered or printed in the phone book or medical society directory. 11.​ A courtesy title is used. (Use Mr., Mrs., Miss, or Ms. or, if gender is unknown, use Mr.) 12.​ Do not use Dr. before the physician’s name if MD follows. 13.​ Use the box number if a street address and box number are given. 14.​ The words North, South, East, and West preceding street names and Road, Street, Avenue, and Boulevard are not abbreviated. 15.​ The words Apartment and Suite are typed on the same line as the address and are separated by a comma. Apartment may be abbreviated if the line is long. 16.​ The name of the city is spelled out and is separated from the state by a comma. 17.​ The state name can be spelled out or abbreviated and is separated from the ZIP code by one space; there is no punctuation between the state and the ZIP code. 18.​ A proper salutation is “Dear,” followed by the title and the person’s last name. If the correspondence is to a colleague or friend, a first name is appropriate. (Ask the physician.) When writing to a business, use “Dear Sir” or “Dear Madam.” 19.​ To use a reference line regarding a patient, type “RE:” and then the patient’s full name and date of birth. (The reason for including the date of birth is to be sure the report is attached to the correct patient chart when received by the referring provider.) This line goes two spaces below the salutation, flush with the left margin in block style. It may be lined up with the date and follow the address in the modified block style. It is a common error to type the reference line before the salutation because that is where most providers who dictate correspondence name the person. 20.​Always double-space between paragraphs, flush left with block style, and indent five spaces with modified block. 21.​ If a second page will be necessary, stop the first page at the end of a paragraph if possible. If not, include at least two lines from the broken paragraph at the bottom of the first page. 22.​The bottom margin must measure at least one inch. 23.​The last word on a page cannot be divided. 24.​Capitalize only the first word of a complimentary closing; follow it with a comma.  25.​The formality of the letter determines the closing: “Cordially,” or “Sincerely,” is considered informal, whereas “Very truly yours,” is more formal. 26.​The sender’s name is entered four spaces below the closing, exactly as on the letterhead; an official title follows on the same line, separated by a comma, or it can be typed on the next line with no comma. 27.​ The typist’s initials, in lowercase, are placed two spaces below the sender’s name. When the sender will not be signing the letter, both the dictator’s (in uppercase) and the typist’s initials are used. Typists do not use their reference initials on the letters they sign. 28.​When items will be enclosed with the letter, enter “Enclosure” or “Encl.” one or two lines below reference initials; number and identify if more than one enclosure is included. 29.​If copies are sent to others, enter “cc” (for carbon copy) and the other receiver’s name one or two spaces below the initials or last notation. When more than one individual is carbon copied, list their names alphabetically or by rank. When a copy is sent to another person without the knowledge of the recipient, it is known as a blind carbon copy (bcc). No notation is placed on the recipient’s letter, but bcc is placed on the file copy to indicate it was sent. 30.​A postscript (PS) is entered two spaces below the last notation. 31.​ When using a second page, a heading of the patient’s name, page number, and date is entered either vertically or horizontally, one inch from the top. If the letter does not concern a patient, the receiver is listed. 32.​The letter continues on the third line after the heading; the page should contain at least two lines of a paragraph. 33.​ Print a draft copy and proofread it. You can also use the Print Preview function in Word instead of printing the document. Make any necessary corrections and save the copy. Print the letter on a letterhead. 34.​Prepare an envelope and give a letter to the writer for a signature. Consultation Letters In a specialist’s office, one of the most common letters received is a request from another provider for a consultation with a patient. You will often find it necessary to correspond with the patient if you need to send any special instructions, directions to your office, or other information. Be certain the material has ample time to arrive at the patient’s home before the date of the examination. The content of the correspondence usually covers: ​ The reason for the appointment. ​ The date and time of the appointment. (It should request notification if the appointment cannot be kept and advise the patient of any policy regarding missed or late canceled appointments and associated charges.) ​ A statement saying that if the patient has any questions please feel free to call your office. Be sure to include your office’s phone number. ​ Note: If prior authorization is required by the patient’s insurance company, it should be so stated in an appointment or referral correspondence. ​ The observation is that the office visit will require a follow-up letter from the specialist to the referring provider, identifying the findings, diagnosis, and recommended course of treatment. ​ Handling Office policy determines whether it is sorted and placed on the provider’s desk or the office manager’s desk or whether a combination of both occurs about the type of mail received. -​ The actual processing of the mail may be done by the manager, receptionist, administrative medical assistant, or mail clerk. Your employer might want to review all the mail personally and request that you open only the envelopes and arrange everything neatly on the desk. -​ Refer to the office policy manual, which should give instructions regarding the handling of mail. If no manual is available, the office manager or the provider should be consulted. Following are some generally accepted practices. Referrals are to be given on an insurance basis like HMO, HI.P ​ Sorting the Mail ○​ Any mail marked personal should be placed on the provider’s or office manager’s desk unopened. ○​ Special delivery mail or special messenger mail should be opened immediately. ○​ Mail may be sorted into categories, such as mail from patients, physicians, insurance companies, and miscellaneous sources. ○​ Other classes of mail, such as magazines, professional journals, and newspapers, should be separated from drug samples and advertisements. ○​ The Referral application in an EHR allows for the identification of referring providers, their specialty, authorization number, and authorized visits, which are then transmitted electronically and recorded in the patient's electronic chart. ​ Opening the Mail ○​ To open mail, use a letter opener, paper clips, stapler, and date stamp. ○​ Stack envelopes in the same direction and remove each letter along the flap edge. ○​ Confirm the contents contain the same name and return address. ○​ Some offices may keep the envelope for identification. Date-stamp correspondence and attach enclosures. ○​ Be cautious when opening mail, as it may be suspicious if it is unexpected, addressed to someone no longer at your address, handwritten, lopsided, lumpy, excessively taped, marked with restrictive endorsements, excessive postage, wrapped with string, or has sound. ○​ Handle contaminated letters or packages, wash hands, and notify the U.S. Post Office and local law enforcement authorities. ​ Processing the Mail ○​ In the office, follow office policy and provider preference when processing incoming mail, including routine expenses, invoices, insurance forms, and checks for deposit. ○​ Ensure to endorse stamp checks and seek a witness to verify the amount of money received. ○​ Providers should review and initial patient-related hospital summaries, operative notes, and other reports before filing. Place requests in a designated area for daily response. ○​ Annotate incoming mail and identify important points for the physician. Providers should receive daily notifications of meetings, miscellaneous correspondence, and professional journals. ○​ Store items for future reference in a designated file and verify the policy with the provider and office manager. Log drug samples on an inventory sheet and secure them for future use. ​ Mail received during vacations ○​ When a provider is away for professional meetings or vacation, it's crucial to read all mail carefully and decide how to handle urgent mail. Consult with a partner or on-call provider to review mail, especially for urgent medical matters. ○​ Send copies of documents and comply with HIPAA regulations. If multiple envelopes are needed, number them consecutively and keep track of them.  ○​ If the office is closed temporarily or permanently, complete a form to have mail held or forwarded to another address. Request "Hold Mail Service" from the USPS website for safe mail storage from 3 to 30 days. Preparing Mailings The USPS uses some of the most advanced, innovative technologies for reading and sorting mail. These advanced technologies read the address on the envelopes you mail, so you must address the envelopes properly to aid in accurate reading and efficient delivery. Addressing the Envelope Addresses are read by computers using optical character readers (OCRs). The address must be typed or machine-printed to be eligible. Use a standard type font because script or executive-type letters run together. For domestic mail, the post office city, state, and ZIP code or ZIP + 4 should appear, in that order, on the bottom line of the address. However, if all three elements do not fit on that line, the ZIP code or ZIP + 4 (postal number may be placed on the line immediately below the post office and state, aligned with the left edge of the address block. The standard two-letter state abbreviations should also be used. The ZIP + 4 codes should always be printed as five digits, a hyphen, and four digits. -​ Mail addressed to foreign countries should include the country name printed in capital letters (no abbreviations) as the only information on the bottom line. Use an envelope of the proper size. Envelopes smaller than 3 ½ * 5 inches do not meet standards. Envelopes larger than 6 ⅛ * 11 ½ inches are acceptable but must be processed by hand and will require additional postage. Stamp or Meter Mail Mail may be either stamped or metered. Stamps may be purchased at a post office or purchased online and printed. If you have a large volume of mail, it is preferable to use a postage meter.  -​ Meters offer features such as a moistener to seal the envelopes (usually at a fixed cost to purchase). This allows you to enter many envelopes for mailing (such as monthly comprehensive physical exam reminders) at a bulk rate. You also save time by not having to go to the local post office. To expedite the processing of metered mail, remember to (1) check and change the date on the meter daily, (2) apply the correct amount of postage by weighing the mail before affixing postage, (3) check the imprint to be sure it is clear and readable, and (4) use fluorescent ink in the meter. An EHR reduces costs associated with mailing correspondence by generating appointment reminders, sending letters and lab reports via a patient portal, and providing online registration forms. This saves practice time and money by eliminating the need for mailing. Mail Classifications The USPS has many informative bulletins and booklets regarding the classifications, mailing standards, special mailing services, and other customer services they offer. If you have special mailing needs, consult with your local post office for advice and up-to-date regulations because they tend to change periodically. Special Mailing Services If you have mail returned because the patient has moved and left no forwarding address, refer to the patient’s chart and demographic form. Try contacting the patient’s alternative phone numbers for current information, but be careful to follow HIPAA guidelines and the patient’s CCP. When a letter is returned after an attempt has been made to deliver it, you must prepare a new envelope and put it on new postage before remailing it. A letter is sometimes returned if you have made an error, such as transposing numbers in an address. Confirm you are using the correct address. -​ To comply with HIPAA rules, use registered mail with an adult signature and confirmation for confidential correspondence. Check the patient's chart and CCP for restrictions on sensitive personal information. Use restricted-type mail when sending lab reports or business communications.