Review Tip. Become familiar with the various correspondence formats and materials discussed in this chapter. Look for examples in your workplace, among your own business mail, or in other available sources. Overview.
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Become familiar with the various correspondence formats and materials discussed in this chapter. Look for examples in your workplace, among your own business mail, or in other available sources.
Written communication in the medical office takes many forms. E-mail, patient instructions, faxes, and various computer applications have been discussed in previous chapters. This chapter concentrates on written correspondence involving mail and transcription. The topics are generally prescriptive, which means they follow a custom or rule.
The majority of letters generated in the medical office follow a template, or form, which is recommended by the physician’s attorney, insurance carrier, or professional organization. The purpose is to protect the doctor from medicolegal risk. The few original letters are usually those dictated by the physician and sent to other physicians regarding patient findings or treatment. The medical assistant or medical administrative specialist must know the correct format, materials, and process for outgoing and incoming mail.
■ Letterhead—quality bond stationery used for the first page of correspondence; contains the name of physician or group, address, telephone number, and e-mail address (if appropriate), usually at the top of the page; white, gray, or buff paper is most common
■ Following pages—plain quality bond stationery that matches the letterhead
■ Envelopes—no. 10 is the size most commonly used because it fits 81/2'’ × 11'' paper folded in thirds; should be made of quality bond paper that matches the letterhead used for letters; lower-quality envelopes with clear windows may be used for patient statements that are folded to exhibit patient’s address through the window
■ Resources—medical offices have various books and other sources, including the Internet, to ensure that the grammar, spelling, and format for correspondence are correct. Some helpful resources are:
• Desk dictionary
• Medical dictionary/encyclopedia (the exams usually have questions on misspelled words)
• Writing style books
• Physicians’ Desk Reference (PDR)
• Other medical reference books
• Date stamp—used to imprint date received on all incoming mail
• Full block—all lines begin at left margin; this is the most common style
• Modified block—subject and complimentary closing and signature begin at the middle of the paper; other lines begin at left margin
• Semiblock (indented modified block)—subject and complimentary closing and signature begin in the center, and the first line of each paragraph is indented five spaces; all other lines begin at the left margin
• Simplified—the greeting and complimentary closing are omitted; all lines begin at the left margin
• Margins—the blank space or border around the text on a business letter; the standard margin is 1 inch
• Date—keyed 15 lines from top of page or 2 to 4 lines below letterhead; key in full date: January 1, 2010, not 01/01/2010
• Inside addresses—the sender’s address is located on the letterhead; the recipient’s address referred to as the inside address, is keyed at the left margin; abbreviations in addresses should not be used except for the state
• Salutation (greeting)—keyed at the left margin, two lines below the recipient’s address, followed by a colon
• Subject (optional)—topic of letter, keyed two lines below salutation, usually at the left margin; sometimes begins with “RE:” (“regarding”)
• Letter body—begins two lines below the salutation or the subject line; the position of the paragraph beginning depends on the style of the letter
• Complimentary closing—two lines below the last sentence of the letter body; if the closing contains more than one word, only the first word is capitalized
• Keyed signature—usually four lines below the complimentary closing; use titles before or after name, not both (e.g., Dr. James Jones or James Jones, M.D., not Dr. James Jones, M.D.)
• Reference initials—two lines below keyed signature; the initials of the individual signing the letter in uppercase letters followed by a colon and the initials of the individual processing the letter in lowercase letters
• Enclosures—two lines below the reference initials; indicates that other items are included with the letter; may simply state “enclosures,” or it may be followed by a colon and the titles of the enclosed document(s)
• Copies—“cc:” or “Cc:” (computer software often automatically capitalizes the first “C”) literally means carbon copy, but is still used to indicate that a copy of the document is being sent to the person whose name follows the “cc:”; this notation is listed one or two lines below the reference initials; when more than one person is copied, the names are listed in alphabetic order
• Envelope addresses
- Start address 14 lines down from top of envelope and 4 inches from left edge when using a no. 10 envelope
- Do not use punctuation except when using expanded zip codes
- Use all uppercase letters
■ Classifications—different types of mailings require different postage and handling costs. Generally, the speedier the delivery is, the more expensive the postage. The following classifications are in order according to the cost (most expensive to least expensive) and the speed of delivery
• Express Mail®—delivery guaranteed the following day
• Registered MailTM—first-class mail insured for a named value
• Certified MailTM—first-class mail with a verification from the postal service that it arrived at the designated address; the sender, for an additional fee, may request a signature for the correspondence indicating who received it; the sender has the option to use the United States Postal Service’s (USPS) “NetPost” Internet service or to take the correspondence to the post office
• First-Class Mail®—postage generally used for office correspondence, including patient statements; weight must be 13 ounces or less
• Priority Mail®—first-class mail handling for items 70 pounds or less; usually takes 2 to 3 days to arrive
• Standard MailTM (bulk)—postage used for magazines, periodicals, newspapers, catalogs, and flyers; requires a minimum of 200 pieces; formerly called second- and third-class mail
■ Mail payment methods
• Postage meter—purchased or leased printing machines or services that print postage directly onto mail pieces or labels; postage-metered envelopes do not need to be canceled and therefore save time; meter date is automatically or manually changed daily; postage meter services may be purchased online
■ Incoming mail procedure
• Stamp items with date received
• Staple or paperclip original envelope to incoming mail piece
• Stamp payment checks with endorsement
• Ensure all envelopes are empty before disposing of them
• Sort according to type
• Check clinical mail for urgency
• Distribute mail to appropriate staff
• Carry out any assigned functions related to the mail, such as posting payments
Two other types of correspondence important to medical offices are memorandums and transcription. Questions on these topics may be on the national exam.
Interoffice correspondence is usually in the form of a memorandum (plural is memorandums or memoranda), or memo.
• Date—the day the memo is written; placed 13 lines from top of the page, with a 1-inch side margin; left justified
• To—the parties to whom the memo is directed; two lines below “Date” line
• From—the name of the party sending the memo; two lines below “To” line
• Subject—the topic of the memo; two lines below “From” line
• Message—begins three lines below “Subject” line
• Hard copy sent to individual staff members
• Hard copy posted in office
• Electronic mail
Transcription is the conversion of the dictated word of the health care provider to a word-processed form. Letters and patients’ medical histories and treatments are the most common transcribed documents in the medical office. Transcribed documents involving the patient become part of the patient’s medical record. The rules of confidentiality apply, including when these documents may be mailed to other entities.
The transcriber should always check with the health care provider if in doubt about any portion of the document; never guess. The format used is based on the type of document and the facility preference. Accurate transcription requires the following:
• Transcriber with digital counter, foot pedal, and earphones
• Word processing tools
• Medical dictionary/spell checker
• Drug reference book/software
• Diagnostic and procedural code sources
• Grammar book/checker
A significant amount of transcription is being replaced by the electronic medical record.