11. Written Communications

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Until 20 years ago, almost all written communication between the medical office and other parties was managed by letters or forms and mailed through the U.S. Postal Service. Today, it is also common to transmit data electroni­cally or by fax, and these data can be viewed and/or printed in written form. Regardless of how the written material is transmitted, however, written communication must still adhere to professional standards. The medical assistant is often responsible for preparing letters, memoranda, reports, and other types of written communication. To do this pro­fessionally requires thorough knowledge of grammar, spell­ing, format, and the technology that supports modern methods of producing written documents. In addition, the medical assistant must be familiar with the implications of Health Insurance Portability and Accountability Act (HIPAA) regulations regulating access to patient health information. These regulations were covered in detail in Lecture 3. The procedure for obtaining consent to release information from the medical record was discussed in Lecture 36.


Letters leaving the medical office—whether sent to a refer­ring physician, an attorney, another business, or an insur­ance company—require proper formatting. Some letters may be dictated by the physician and transcribed by the medical assistant. He or she may also compose and send letters independently. The medical office may also use form letters and/or templates for routine matters. A template is a standard form to which additional data can be added as needed.

Equipment and Supplies

Business letters are usually created using a computer and printer. A word processing program is used to create the letter so that formatting can easily be adjusted and any necessary corrections can be made.

The medical office orders stationery and envelopes pre­printed with the practice name, address, telephone number, and business logo. Individual physician names are also often included. A sheet of this type of stationery is called letter­head. Blank sheets of the paper of exactly the same type and weight must be purchased for letters that are longer than one page. Photocopies of letters printed on letterhead are often retained for office records in addition to the com­puter file used to create the letter.

Parts of a Business Letter


The heading includes the return address and the date line. The return address is composed of the name and address of the business sending the letter. If office letterhead is used, no return address needs to be added. The date line is the date the letter is mailed in month, day, year order. The month is written out in full on the date line. It is usually entered on the second or third line below the return address. On letterhead stationery, it is placed to fall a few spaces below the bottom of the letterhead.

Inside Address

The inside address includes the name and address of the party to whom the letter is being sent. Beginning with the inside address, information is single spaced with a blank space between sections. The inside address should be located in a position so that the body of the letter is centered top to bottom on the page. If the letter is long enough to require two pages, the inside address begins on the second or third space below the date line.

Salutation or Greeting

The salutation (the greeting that begins a letter) is found below the inside address. A business letter is formal, so the recipient’s last name and title (e.g., Mr., Ms., Miss, Dr.) should be used. The salutation is punctuated with a colon. Correct examples include the following:

Dear Ms. Wilson:

Dear Dr. Taylor:

Dear Mrs. Porto:

Titles or initials indicating credentials (such as MD or RN) are not used after names. The following are incorrect: Dear Amy,

Dear Amy Wilson:

Dear William Taylor, MD:

If the recipient’s name is not known, it is permissible to use “Dear Sir,” “Dear Madam,” “Dear Sir or Madam,” or “To Whom It May Concern.” One line is left blank after the salutation.

Body of the Letter

The body of the letter contains the content, which should be presented clearly and concisely. A subject line may be used to begin this section. Within a paragraph the letter is single spaced, but a blank line should separate each new paragraph.

Complimentary Closing

The complimentary closing (or complimentary close) is a term for the words used as a polite ending to a letter just before the writer’s signature. It is a sign of respect and can be adjusted depending on how well the letter’s author and the party being addressed know each other. “Sincerely” is the standard close. A more formal closing is “Yours truly” or “Very truly yours.” It is followed by a comma and sepa­rated from the body of the letter by a blank line.

Signature, Printed Signature, and Title

The signature is the actual written signature of the indi­vidual sending the letter. It is added after the letter has been printed. The signature line contains the printed signature of the individual sending the letter, with credentials (e.g., MD). It is entered four to five lines below the complimen­tary close to leave room for the written signature. A business title (e.g., Office Manager) is capitalized if used and entered on the line below the printed signature.

The medical assistant uses his or her own name and signature for a letter to a supplier or a letter to a patient responding to a billing question. Any letter dictated or composed by a physician will be signed by the physician.

End Notations

Various pieces of information may be given in notations at the bottom of the letter, generally with a blank line between each item. The order of the end notations may vary according to the preference of the office. A reference nota­tion notes the initials of the person who composed the letter (in uppercase) followed by the initials of the person who typed or keyed the letter (in lowercase). If the letter contains enclosures, such as a log of visits and/or billing records, this is noted in the enclosure notation, on the second line below the title. “Enclosure” or “Enc.” may be used for one enclo­sure. “Enclosures” followed by the number in parentheses is used for more than one enclosure. This alerts the recipient to make sure that everything the sender intended to include actually accompanies the letter. A copy notation (distribu­tion notation) identifies the recipient(s). The letter “c” is used, followed by a colon and the name(s) of those who are receiving copies. Figure 42-1 shows a business letter with the parts of the letter identified.

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Figure 42-1 Sample business letter with the parts of the letter identified.

Format of Business Letters

Setting up a Letter

When preparing letters using a word processing program, the first step is to set the margins. The top margin of the letter should be large enough to accommodate the letter­head (usually 2 to 212 inches). The side margins may be 1 to 2 inches. Wider margins are used for a short letter. The body of the letter is single spaced.

In writing a business letter, a generally accepted font is Times New Roman 12 point. The entire letter should be created in the same font. The word processing program may include a letter wizard, which formats the letter automati­cally. It is also possible to use or create a letter template so that all letters from the office have the same format.

If the letter has two pages, a header should be placed at the left top margin of the second page with the name of the recipient, the page number, and the date.

Letter Styles

        Full block style: The letterhead may be centered, but all other lines are left justified, which means that they start at the left margin on the page. This allows rapid entry of information and easy formatting. A double space is left between the end of one paragraph and the beginning of the next (Figure 42-2).

        Modified block style: All lines in the inside address, salutation, and body of the letter and reference lines are left justified, and there are double spaces between para­graphs. However, the date line, complimentary close, and signature lines begin in the center of the letter or are sometimes right justified (aligned with the right margin) (Figure 42-3).

        Semiblock style (also called modified block with indented paragraphs)-. All lines in the inside address, salutation, and body of the letter and reference lines are left justified. Paragraphs are indented five to eight spaces, and there are double spaces between paragraphs. The date line, complimentary close, and signature lines begin in the center of the letter or are sometimes right justified. Semi­block style is the same as modified block style, except that the first sentence of each new paragraph is indented (Figure 42-4).

        Simplified letter style: This style resembles a memoran­dum. Instead of a salutation, a subject line typed all in capital letters is placed three lines below the inside address, and the complimentary close and signature lines are replaced by an all-capital-letter signature five lines below the letter’s body (Figure 42-5).

Composing a Business Letter

A medical assistant may be asked to create a form letter to send to patients or compose a business letter to order sup­plies, request information, or handle a problem. In addition to using a professional tone, it is important to use correct grammar and spelling to convey the desired information.

Before beginning the letter, it is a good idea to jot down the important points to cover in the letter and check to make sure they are presented in a logical order. If the office sends similar letters fairly often, it is helpful to review the wording of old letters. Once the content has been estab­lished, the medical assistant should enter the letter into the word processing program using the letter style preferred by the medical office. If he or she is unsure about the wording of the letter, a draft letter can be printed for the office manager and/or physician to review.

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Figure 42-2 Sample letter—full block style.

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Figure 42-3 Sample letter—modified block style.

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Figure 42-4 Sample letter—semiblock style (also called modified block with indented paragraphs).

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Figure 42-5 Sample letter—simplified style.

The letter should be proofread for accuracy, grammar, and spelling before the final version is printed. Because letters represent the medical practice, they must be as accu­rate and professional as possible (Procedure 42-1).

Responding to Written Communication

On a daily basis the medical office receives letters and/ or e-mails that require follow-up. Unless letters are marked “personal” or “private,” the medical assistant usually screens correspondence. He or she may respond person­ally to correspondence related to supply orders, billing questions, insurance-related questions, and requests for information about the practice. If an urgent response appears necessary, the telephone can be used, but in most cases the response will be in the same format as the original communication.

Correspondence relating to patient care is referred to the physician, and the medical assistant may clip the letter to the patient’s medical record if a paper-based medical record system is used in the office. If the physician dictates a reply to a letter, the medical assistant may transcribe the letter or edit a letter dictated using voice recognition software.

Highlight on Letters to Inform Patients of Test Results

Although medical offices use many different methods to inform patients of results of laboratory and diagnostic test results, notify­ing patients by letter is a method that preserves patient confiden­tiality and provides consistent and reliable information to the patient about follow-up. Studies have shown that patients prefer to receive all results, whether or not they are normal.

Many medical practices use templates or form letters that allow the medical assistant or physician to fill in the appropriate values and add comments. The final letter may include the actual results or a general statement about the results (e.g., “All your blood test results are within normal limits.”) Specific time frames for follow-up testing or instructions to make a follow-up appointment are also included.

If the practice uses an electronic medical record, test results can be tracked in the system to be sure that results have been received from the laboratory or testing facility. It is also possible to track that the patient has been notified and follow-up testing has been performed. The system can also post an alert when follow-up testing is overdue. If the office uses a paper-based medical record, a separate log book can be kept for laboratory and diagnostic tests to track receipt of results, review by physicians, and follow-up to patients.

As a means of managing physician time efficiently while main­taining the personal touch, the medical assistant may prepare the letter, enter the information about the laboratory results, and place the letter with the test results for the physician to verify accuracy, sign the letter, and add any comments. ■

PROCEDURE 42-1 Composing a Business Letter

Outcome Compose and key a business letter.
• Letterhead stationery• Typewriter
• Blank stationery• Computer and printer

         Procedural Step. Assemble materials, determine the address of the recipient, and decide on a format for the letter.

         Procedural Step. Formulate the content for the busi­ness letter. List and organize the essential content to be sure all necessary information is included.

         Procedural Step. Insert the date on the second or third line below the letterhead. For block style, the date is at the left margin. For modified block style and semiblock style, the date begins at the center of the line.

         Procedural Step. Place the inside address four to 10 lines below the date at the left margin. If using a computer, adjust the number of spaces below the date line after the letter has been keyed so that the body of the letter is centered on the page.

         Procedural Step. Place the salutation on the second line below the inside address. The salutation should include a title and the person’s last name (e.g., Dear Dr. Gordon, Dear Mrs. Wilson, Dear Rev. Meyers). It is followed by a colon.

Principle. A business letter is more formal than per­sonal correspondence.

         Procedural Step. If desired, place a subject line on the second line below the salutation. A subject line begins with the Latin abbreviation “re” (meaning about) fol­lowed by a colon. The abbreviation is usually capital­ized (e.g., RE: Annual meeting on Thursday, June 12, 2010).

Principle. Although optional, a subject line helps the recipient identify the subject of the letter before reading it.

         Procedural Step. Begin the body of the letter on the second line below the salutation (or subject line, if used). The body of the letter is single spaced and double-spaced between paragraphs. In block and modified block letter styles, the paragraphs begin at the left margin. If semiblock style is used, indent the first line of each paragraph five to eight spaces.

          Procedural Step. The final paragraph of the letter should summarize the contents and/or most impor­tant ideas.

          Procedural Step. Place the complimentary close on the second line below the final paragraph of the

body of the letter. For the block letter style, the com­plimentary close begins at the left margin. For the modified block letter style, it begins at a tab directly below the date line. The complimentary close is fol­lowed by a comma.

             Procedural Step. Drop down four lines and insert the first and last name of the sender followed by his or her credentials. Begin the typed signature directly under the complimentary close. Place a job title, if appropriate, on the next line.

Principle. Typing the name under the handwritten signature facilitates a response because the signature may be difficult to read.

             Procedural Step. If necessary, add a reference line, enclosure notation, and/or distribution notation, below the typed signature at the left margin. Double space between each notation. If you compose and key your own letter, a reference line is unnecessary. If you compose and key a letter for someone else, place your initials in lowercase letters. If you key a letter that was dictated by the person signing the letter, place his or her initials (uppercase) followed by your initials (low­ercase) separated by a colon or slash. The enclosure notation may be written out or abbreviated “Enc.” The number of enclosures is placed in parentheses if there is more than one. The distribution notation identifies individuals who receive a copy of the letter. The letter “c” followed by a colon is used with the name of the individual receiving a copy.

Principle. The person who receives the letter is enti­tled to know who prepared the letter and who received copies. If the number of enclosures is indicated, it is easier to tell if all intended material is enclosed with the letter.

             Procedural Step. If the letter is longer than one page, the second page should be printed or typed on stationery of the same quality and weight as the let­terhead stationery, beginning 1 inch from the top. Include the name of the recipient, the date, and the page number in the top left corner. Space the letter so that at least two lines of the body of the letter continue to the second page.

             Procedural Step. Spell -check the letter and proofread it carefully. If using a computer, print the letter.

Principle. A business letter should not contain errors. If errors are present, the credibility and professional­ism of the sender may be doubted.

             Procedural Step. Obtain the appropriate signature or sign the letter below the complimentary close.

       Procedural Step.                                              the letter for

your files and for any individual who will receive a copy of the letter.

Principle. Copies of all business letters are retained in case there are questions or further correspondence is necessary.

16. Procedural Step. Prepare an envelope (see Chapter 43, Procedure 43-3) and place the letter in the desig­nated area to be prepared for mailing. If the letter concerns a patient, a copy of the letter is filed in the patient’s medical record. Other letters (e.g., letters to suppliers) are usually filed in folders by subject.


It is important to respond in a timely manner to written communication using proper grammar and spelling. Grammar is a term for the accepted rules to create mean­ingful sentences in a language.

Parts of Speech

In English, words are classified as one of eight different parts of speech, a set of categories that describe how words are used. Many words can be used in more than one way.

                  Nouns: A noun is the name of a person, place, or thing. It can also be a word used to identify a concept or idea. Common nouns refer to general things or categories (e.g., tree, house). Proper nouns are names of specific individuals or places (e.g., John Stanton, Philadelphia).

                   Pronouns: A pronoun is used in place of a noun. Examples include I, me, you, he, she, it, and they. Pos­sessive pronouns show ownership (e.g., mine, yours, hers, its). None of the possessive pronouns are written with an apostrophe.

                   Verbs: A verb shows either action or a state of being. Every sentence requires a verb in order to be com­plete. Verbs that show a state of being are also called linking verbs. Action verbs include talk, singg, help, and communicate. Verbs that show a state of being include is, are, feel, and seem.

                   Adjectives and articles: An adjective modifies or qualifies a noun. It is a describing word. Examples include white, pretty, little, and thin. When two or more words are used together as an adjective to modify or qualify a noun, they are often connected by a hyphen (a 20-year-old woman). English has three articles: a, an, and the. They may be included as adjec­tives or sometimes a separate part of speech.

                   Adverbs: An adverb modifies a verb, adjective, or other adverb. Adverbs include words that question (how? where?) and words that end in -ly (slowly, perfectly).

                   Prepositions: A preposition shows the connection of a noun or pronoun to some other word, especially in relation to space, time, or possession. Examples include on, in, of, and to.

                    Conjunctions: A conjunction joins words, phrases, or clauses in a sentence. The common conjunctions include and, but, or, and because.

                    Interjections: An interjection is a word that expresses feelings. It is often followed by an exclamation point. Examples include oh!yeah! and ouch! Interjections are rarely used in correspondence or reports.

Sentence Structure

Sentences are composed of various combinations of inde­pendent and dependent clauses. A clause contains a subject (noun or pronoun) and a verb. If it can stand alone, it is

Putting It All into Practice

My name is Christine Walters, and I am a Registered Medical Assistant. I have been working for a nephrology practice for the past 3 years. This practice was started by two doctors about 15 years ago, and their office is in a building located next to the local hospital. About a year ago a third nephrologist joined the practice, and it is surprising how much more paperwork this has created. Because the physicians specialize in diseases of the kidney, our patients are usually referred by other physicians. This means that our physicians must communicate with the patient’s primary care physician for almost every patient they see. Our physicians use handheld digital recorders that are connected to our computer network. One of the physicians prefers to have his reports format­ted as a consultation report, which is sent with a cover letter to the referring physician. We use a template for the cover letter so that he doesn’t have to dictate it each time. The other two physi­cians usually include their findings in a letter. I am responsible for preparing these letters and reports, but it really isn’t difficult because they follow a fairly regular pattern. The physicians create the letters and reports using voice recognition software. I proof­read and format each letter as needed, then print a final copy for mailing to the referring physician after it has been signed. It may take me up to 2 hours a day, and when the office is busy, some­times I do get behind and I may even have to stay late to finish. I have been able to personalize the spell-checker on the computer I use, so even proofreading isn’t that difficult. ■

Case Study 1

The physician asks Christine to send letters to obtain brochures with information about different types of electrocardiograph machines. He gives her the name of two manufacturers in which he is interested. The physician says, “I don’t want to talk to anyone yet. I just want to see some brochures.” ■

called an independent clause. If it requires an additional

clause in order to be meaningful, it is called a dependent or

subordinate clause. Sentence classifications are as follows:

                  Simple sentence: A sentence composed of one inde­pendent clause. Example: The dog was very hungry.

                   Compound sentence: A sentence composed of two independent clauses connected by a conjunction. A comma separates the two clauses. Example: The dog returned from its walk, and it drank all the water in its bowl.

                   Complex sentence: A sentence composed of one independent clause and one or more dependent clauses. If the dependent clause begins the sentence, it is followed by a comma. Example: When it returned from its walk, the dog drank all the water in its bowl. If the dependent clause comes after the independent clause, the dependent clause is not separated by a comma. Example: The dog drank all the water in its bowl when it returned from its walk.

Sentence Errors

         Sentence fragment: A sentence fragment is a dependent clause used to stand alone as a sentence. In this case, an additional independent clause is necessary for meaning. Sentence fragment: When I arrive for my appointment. Correct sentence: When I arrive for my appointment, I

will bring my insurance card.

         Run-on sentence: A run-on sentence is a sentence in which two or more independent clauses are joined without a conjunction.

Run-on sentence: My appointment is on Thursday I will bring my insurance card.

Correct sentence: My appointment is on Thursday, and I will bring my insurance card.

         Comma splice: A comma splice is the incorrect use of a comma to separate two sentences. The sentences should be separated by using a period and beginning a new sen­tence or by using a semicolon. It is also permitted to sepa­rate the sentences with a comma and a conjunction.

Comma Rules

                Use a comma to separate the elements in a series of three or more things. The comma before the conjunc­tion “and” is optional.

Example: The patient complained of abdominal pain, difficulty breathing, and headache.

Example: This 40-year-old, well-nourished, Caucasian woman was seen on 12/22/20.

         Use a comma before a conjunction, such as “and,” “but,” or “for,” when the conjunction connects two independent clauses. An independent clause could be used as a complete sentence.

Example: The patient called an ambulance, and the ambulance brought her to Memorial Hospital. Example: We gave the patient furosemide intravenously, but after an hour her urine output was still poor.

         Use a comma to set off introductory elements such as prepositional phrases or dependent clauses.

Example: After the upper GI, the patient continued to

experience epigastric pain.

Example: Because we were planning surgery for next week, I did not want to prescribe any new medications.

          Use a comma to set off information that could be omitted or placed in parentheses without changing the meaning of the sentence.

Example: The patient, who was referred by Dr. Jenkins, is a 40-year-old woman in good health.

Example: We will follow this patient closely in the clinic, which is open on Tuesdays and Thursdays.

          Use a comma before quotation marks except at the end of the sentence where a period precedes the close quota­tion marks. Do not use a comma to introduce quoted elements introduced by the word that.

Example: The patient said, “My incision burns like fire.” Example: “My incision burns like fire,” said the patient. Example: The patient states that her incision burns like fire.

          Use a comma to avoid confusion.

Example: For most the year is already finished. Example: For most, the year is already finished.

          Use a comma between the city and the state, the date and the year, a name and a title, and in long numbers. No comma is necessary when only the month and year are used.

Example: The patient was admitted to Memorial Hos­pital, Westford, Massachusetts in late July 2002. Example: On July 5, 2002 the patient was burned severely in a fire in Las Vegas, Nevada.

          Use commas with terms like not, however, and but to express contrast.

Example: The wound was large, but healing well. Example: I had not prescribed antibiotics for the patient before; however, she had obtained them from another physician.

          Use a comma to separate appositives, nouns of direct address, titles that follow a person’s name, and intro­ductory words from the rest of the sentence.

Example: We will make an appointment with Dr.

Cannon, a gynecologist, sometime next week. Example: Doctor, there is something else I wanted to ask you.

            Separate parenthetical expressions from the rest of the sentence using commas. These expressions include the following: I believe, I am sure, on the contrary, indeed, of course, nevertheless, in my opinion, and in fact.

Example: The report, I hope, will give you more infor­mation about multiple sclerosis.

Example: An inadequate supply of oxygen to the myo­cardium, for example, is caused by narrowing of the coronary arteries.


Although word processing programs usually provide a spell­check feature, the medical assistant must still proofread all documents for spelling. The spell-check function verifies the spelling of a given word but cannot confirm that it is the intended word or that it is used correctly in context. See Box 42-1 for a list of pairs of words that are commonly confused.

A tool to improve spelling is a personal list of words that cause difficulty. It is important to make an effort to learn these words, and remember to spell-check these words every time they are used. The medical office may purchase a medical dictionary program that can be installed on office computers for reference.


After preparing any letter or document, the medical assistant should spell-check or look up any unfamiliar words in order to spell them correctly. Abbreviations for medical conditions should be written out, but abbreviations for medication times, measurements, and vital signs are usually acceptable.

It is helpful to use medical spell-check software, which is available from several companies. An ordinary spell-check program can also be personalized over time by adding medical words and abbreviations that the program does not recognize; however, additions should always be checked for correctness. After the document or letter has been keyed, the medical assistant should print a copy, proofread it (read it carefully and make corrections), and then correct it and print out a final copy. If there is an unintelligible word, a space can be left and marked in pencil for the physician to fill in before the final copy is printed. Figure 42-6 is a list of proofreader’s marks.


A common way to communicate within the office is through the use of a memo (memorandum), a document used within a company that is usually short and limited to one subject. Although a printed form can be used, it is not dif­ficult to produce a template that can be used frequently in a given office. The title “Memorandum” or “Interoffice Memorandum” should appear at the top of the page.

Four headings commonly appear at the top of the memo:





The headings may be separated from the body of the memorandum by a line that extends from 2 inches to completely across the page. The message should be informa­tive but succinct. The body of the memo is single spaced. A memo may be printed and circulated to all individuals included in the distribution list, or it may be sent as an e-mail attachment. If the memo is written to all staff members, a copy may be posted on a central bulletin board (Figure 42-7).



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Figure 42-6 Standard proofreader’s marks.

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Figure 42-7 A memo is used for communication within a business.

E-mail (electronic mail) has become an accepted means of communication throughout the business world. E-mail is the exchange of information from one computer to another. As described in Lecture 38 a computer with an Internet connection is used to send e-mail. Medical assistants usually use e-mail to communicate with business contacts, not patients. These may include other medical assistants, vendors, and insurance companies. It is usually faster and more efficient to send an e-mail for a short message.

An e-mail message should contain an informative subject line. Successive e-mails relating to the same subject are usually created as a reply so that the recipient can read the previous correspondence related to the subject. It is polite to acknowledge receipt of an e-mail, even if there is no reply, so the sender knows that the e-mail has been received.

The tone of an e-mail is somewhat less formal than that of a letter, but correct grammar and spelling should be used without any of the abbreviated forms that are sometimes used in personal e-mails. Humor should be avoided because the recipient does not have the nonverbal cues to know when a message is meant to be humorous. The medical assistant should also avoid sending an e-mail containing criticism or other negative content because it is easier to be more negative than intended in writing than when speaking directly to an individual.

E-mails usually use plain text. At the foot of the message, the medical assistant should include the business name, contact information, and e-mail address and telephone number. Most e-mail programs allow the medical assistant to create an e-mail signature with the contact information to be included at the bottom of every e-mail.

It is important to remember that e-mails are not private. Even after messages have been deleted, they can often be recovered from the computer or network used to create them. E-mail should be used only for business communications that are straightforward and not confiden­tial. It is also always important to be sure that the e-mail is being sent to the correct recipient. It is a good policy to review the recipient name(s) before hitting the “send” button. The account should be set up so that sent messages are saved, but the medical assistant may also want to create printed copies of e-mails related to orders or billing problems.

Clinical Messaging

Clinical messaging (also called clinical e-mail) refers to electronic messages sent to other health professionals using the electronic medical record (EMR). It is considered as secure as the EMR itself, so it is often used to com­municate information about patients to colleagues. The record of an individual patient can be attached to the message. The format and tone are the same as in an ordinary e-mail.

E-mail Attachments

Programs for sending e-mail allow documents, images, and other types of files to be attached and transmitted with the e-mail. Unfortunately, many computer viruses are spread through e-mail attachments, so attachments should not be opened unless they are from a trusted source and/or are expected. If an attachment does contain a virus, opening the attachment launches the virus. Any e-mail with an attachment from an unknown recipient should be deleted immediately. If a medical assistant sends a file as an attachment, the recipient may also be hesitant to open the file for the same reason.

The format of an attachment may also pose a problem. The recipient may be unable to open the attachment without the software that was used to create the file in the attachment. Document files can always be saved in text format if there is any question about compatible software. Most files can also be saved as webpages, which the recipient can view with his or her Web browser.

Fax Transmissions

Fax Machine

Paper copies of documents can be sent quickly from one loca­tion to another using a fax machine. The word fax is a short form of facsimile and is a method of sending images over telephone lines. The original document is fed into the fax machine, which encodes the images on the paper into signals to be sent over the phone. At the other end, a second fax machine prints black dots on a piece of paper that correspond to the information received. There should be a dedicated

Case Study 3

An order for clinical supplies has been delivered to the office, and Christine is putting the supplies away. While checking the received items against the packing list, she notices that although there are 10 boxes of urine test strips listed, only nine boxes have been shipped. In addition, the packing slip states that only one package of five rolls of paper for the Clinitek machine was shipped, but five packages were ordered. As an experiment, the office has placed this order with an Internet supplier. No tele­phone number is given for the supplier on its home page. On the company’s invoice (bill), which has arrived separately, the medical office has been charged for 10 boxes of urine test strips and one package of paper for the Clinitek machine. ■

telephone line and telephone number for the fax machine, which is shown in Figure 42-8. The phone number for the fax machine should be listed next to each telephone so that any caller can be told how to fax information to the office.

Sending a Fax

The fax is useful for doing business (e.g., ordering supplies) and for sending out meeting agendas or receiving résumés when hiring. To protect confidentiality, fax transmissions of

patient health information should be made only when patient consent has been obtained or in an emergency situ­ation when prompt information transfer is required. A cover sheet should be used for privacy, and the recipient should be notified by telephone when the fax is being sent so that he or she can remove it from the receiving fax machine promptly (Procedure 42-2). The cover sheet should contain a confidentiality statement similar to the one in Figure 42-9.

11. Written Communications 17

Figure 42-8 A fax machine allows transmission of images from one location to another using a telephone line.


The documents accompanying this transmission may contain confidential information that is protected under the Privacy Act of 1974. It is being faxed to you after appropriate patient authorization or under circumstances that do not require patient authorization. This information is intended only for the use of the intended recipient(s). The authorized recipient(s) of this information is/are prohibited from disclosing this information to any other party unless permitted to do so by law or regulation.

If the reader of this message is not the intended recipient(s) or the employee or agent responsible for delivering the attached information to the intended recipient(s), please note that any dissemination, distribution, or copying of this information is strictly prohibited. Anyone who receives this information in error should notify the sender immediately and arrange for the return or destruction of the transmitted information.

Figure 42-9 A medical office should include a confidentiality statement on the cover sheet for fax transmissions.

PROCEDURE 42-2 Sending a Fax

Outcome Send a fax.


Document to be faxed

              Fax machine

              Cover sheet

Procedural Step. Prepare the cover sheet including the name, address, and fax number of the recipient; fax number of the sender; and number of pages (including the cover sheet). If there is a message to the sender, include it on the bottom of the cover sheet. Procedural Step. Organize all pages to be faxed with the cover sheet first.

Principle. Pages should be in order and all facing the same direction.

         Procedural Step. Place pages in the fax machine, face up or face down as is correct for the machine being used.

         Procedural Step. Enter the fax number. Include any extra digits as required, such as a “9” to obtain an outside line, a “1” for long-distance, and/or an area code if required.


PROCEDURE 42-2 Sending a Fax—cont’d

Principle. Some areas of the country have introduced so-called overlay area codes requiring all telephone numbers to be dialed with an area code.

               Procedural Step. Verify the fax number as it appears in the window or on the computer screen to be sure the number is correct.

Principle. To maintain confidentiality, always be sure the fax number has been entered correctly.

               Procedural Step. Press the correct button to send the fax.


It may be necessary to use a copy machine to copy docu­ments of one or several pages (e.g., an article or paper written by a physician) or to make several copies of a docu­ment (e.g., a report to be discussed at a staff meeting). In order to copy efficiently, the medical assistant should become familiar with special features of the available copy machine. Before copying, staples should be removed from the document to be copied, the pages should be arranged in order, and the copy machine should be checked to be sure it has enough paper.

When several copies of a multiple-page document are needed, the machine should be preset to collate (arrange each copy in sequence) or sort the pages if the machine has this feature. Some machines will also staple documents.

         Procedural Step. If the fax contains patient health information, place a telephone call to the recipient so that the fax can be removed from the recipient’s fax machine as soon as it is received.

          Procedural Step. Check back to be sure the fax has been sent. Some machines print a confirmation for every fax, and some print a written report only if the fax does not go through.

          Procedural Step. File the original document appropriately.

For a machine that copies only single pages, the desired number of copies of each page must be copied, arranged in order, and stapled manually. The medical assistant should avoid distractions when copying and should be careful to copy each page correctly and place pages in the correct order (Procedure 42-3).

Another feature of many photocopiers is the ability to duplex, or store images from both sides of a page in memory to produce two-sided copies.

When copying a patient’s medical record, the medical assistant must preserve the confidentiality of the information. Before beginning to make a copy, verify that the patient has signed an authorization for the release of information. After copying, it is important to double-check that no originals or copies were left at the machine. The medical assistant is responsible for shredding any spoiled copies.

PROCEDURE 42-3 Preparing Copies of Multiple-Page Documents

Outcome Prepare copies of documents with multiple pages.




Staple remover

              Photocopy machine


              Document to be copied

         Procedural Step. Assemble all pages of the document or report. If it is stapled, remove all staples.

Principle. Staples may damage the glass or the feeder of the copier.

         Procedural Step. Be sure that the copy machine is on and warmed up.

         Procedural Step. If the report to be copied includes all or part of a patient’s medical record, verify that there is a signed release of information.

         Procedural Step. Place the originals in the machine according to the directions for the individual machine. Principle. Depending on the size and complexity of the machine and the type of document to be copied, it may be necessary to copy one page at a time, or the machine may accept the entire document. The original may have to be placed face down on the glass (single­sheet copying), or the document may be loaded face down or face up into a feeder.

         Procedural Step. Set the size and number of copies, and, if the machine allows, press buttons so that copies will be collated and/or stapled.

         Procedural Step. Press the “start” button.

         Procedural Step. After the copies have been made, if necessary, arrange the pages in the correct order and staple.

          Procedural Step. If the patient will be charged for copying sections of the medical record, verify the number of pages and submit to the person responsible for billing.


When a patient’s protected health information (PHI) must be com­municated in writing, it is always preferable to send the information in a letter instead of writing an e-mail or sending a fax. Although it is possible for a letter to be read by someone other than the addressee, the sender has made every reasonable effort to protect a patient’s confidentiality as required by the Health Insurance Portability and Accountability Act (HIPAA).

If a medical office has a secure electronic messaging system with approved encryption, it may be acceptable to send e-mail messages containing PHI. It is also acceptable to send patient information using clinical messaging. Before any communication with patients via e-mail relating to PHI, the patient should be required to provide consent, recognizing that e-mail is not a secure form of communication. Care should be taken to ensure that an e-mail containing PHI is sent only to the intended recipient.

Fax transmissions should be used only if it is necessary to transmit information without the delay inherent in sending a letter. A cover sheet containing a confidentiality statement should be used, and the transmission should be confirmed by telephone if possible. Neither the sending nor the receiving fax machine should be located in an area that is accessible to unauthorized personnel (to prevent interception of incoming faxes). If a fax that contains PHI is received in error, the sender should be notified immediately and the fax should either be returned to the sender by mail or destroyed. ■

What Would You Do? What Would You Not Do? responses

What Did Christine Do?

           Looked up the two companies mentioned by the physician using the Internet to obtain the exact business names and addresses and model numbers of machines in which the physi­cian might be interested.

           Also looked for other companies that might manufacture similar machines.

           Prepared letters to each company requesting information using the usual format for office letters.

           Used the salutation “Dear Sir or Madam.”

           Proofread and signed the letters before mailing.

           Made a note to herself to follow up after a week.

What Did Christine Not Do?

           Did not ask the physician how to find the addresses.

           Did not initiate a contact that would result in a call by a salesperson.

           Did not send the letters out with an incomplete address or with errors.

What Would You Do/What Would You Not Do?

Review Christine’s response and place a checkmark next to the

information you included in your response. List the additional infor­mation you included in your response.

          Tried to look it up in a dictionary of abbreviations to make sense of the sentence.

          If still unable to identify an appropriate abbreviation, left a blank line in the letter and indicated on a sticky note that the physician should fill in the blank.

          After the letter was reviewed by the physician, corrected the letter and printed a new copy for the physician to sign.

What Did Christine Not Do?

          Did not leave the abbreviation if it did not make sense, hoping that the physician would not notice.

          Did not mail the letter without correcting and reprinting it.

          Did not interrupt the physician to ask about the confusing abbreviation and sentence.

          Did not complain to other office staff about the voice recognition software program.

What Would You Do/What Would You Not Do?

Review Christine’s response and place a checkmark next to the

information you included in your response. List the additional infor­mation you included in your response.

Case Study 2

Page 1017

What Did Christine Do?

□ Asked another medical assistant in the office if she knew what the abbreviation should be.

Case Study 3

Page 1019

What Did Christine Do?

          Used either office e-mail or the contact button on the website to send an e-mail about the missing box of test strips.

          Used the same professional tone in the e-mail that she would have used in a letter or telephone call.

          In the e-mail, included the order number, billing name and address, number of boxes of test strips ordered, and number of boxes of test strips received.


What Would You Do? What Would You Not Do? responses—contd

         In the e-mail, stated clearly that the company should send an additional box of test strips.

         Because the bill charged for only the one package of paper that was shipped, decided to order the other four packages of paper for the Clinitek machine from a more reliable company.

What Would You Do/What Would You Not Do?

Review Christine’s response and place a checkmark next to the information you included in your response. List the additional infor­mation you included in your response.

What Did Christine Not Do?

                 Did not cross out the charge for 10 boxes and test strips and change it to nine boxes when approving the bill for payment without contacting the company.

                 Did not ignore the missing box of strips when approving the bill for payment, assuming that the company would send another box automatically.

                 Did not use casual, critical, or hostile language in the e-mail.


Medical Term

Word Parts



Simplified letter style

Clinical messaging Collate






Full block style Grammar Left justified Letterhead


(memorandum) Modified block style

Proofread Right justified Salutation Semiblock style

Communication among health professionals within the electronic medical record.

To assemble the pages of a document in numeric order.

Words used as a polite ending to a letter just before the writer’s signature.

To produce double-sided copies by storing images from both sides of the original in the memory of a photocopier.

The exchange of information from one computer to another using telecommunication.

Transmission of scanned, printed material by telephone. A short form of the word facsimile.

A letter format in which all parts of the letter are left justified.

The study of accepted rules used to create meaning in a language.

Lines of type that begin at the left margin of a document.

A sheet of stationery preprinted with information about a business, including name, address, telephone number, and other information.

A form of communication within a company that is usually short and limited to one subject.

A format for business letters in which the date line, complimentary close, and printed signature line are on a tab at the center or right justified and all other parts of the letter are left justified.

To identify and correct errors in a document.

Type that is aligned with the right margin of a document.

The greeting that begins a letter.

A letter format in which the date line, complimentary close, and printed signature line are on a tab at the center or right justified, all paragraphs are indented five to eight spaces, and the other parts of the letter are left justified.

A letter format in which all elements are left justified. The greeting is replaced by a subject line in all capital letters. The complimentary close and typed signature are replaced by a typed signature in all capital letters.

A standard form to which additional information can be added as needed.


For information on improving written communication:

Grammar and Spelling—The Purdue Online Writing Lab (OWL): http://owl.english.purdue.edU/owl/section/1/5/ For information on patient confidentiality in written communication:

Centers for Medicare and Medicaid Services—HIPAA Privacy Rule: www.hhs.gov/ocr/hipaa