Written Communication

Skills

Objectives

• 2.31 Recognize elements of written and electronic communication (spelling, grammar, formatting, and confidentiality)

• 2.32 Describe techniques for planning and organizing written documents.

Written Communication

• How important is written communication in the delivery of quality healthcare?

• Think about the last time you received medical or dental care. What do you think had to be communicated in writing?

• Good writing includes:– Logical organization– Attention to detail– Complete accuracy

Organizing Content

• Determine your purpose for writing.• Be sure you consider three important parts:– Introduction– Body– Conclusion

• Create an outline (formal or informal) that will help you organize your ideas.

Spell Words Correctly

• Spelling is critical in healthcare documents. Why?

• Use tools to be sure you get it right.– Medical dictionary– Regular dictionary– Word processing software spell checkers

• Learn major spelling rules.• Memorize difficult to spell words.

Use Proper Grammar and Punctuation

• Why? To give a favorable impression of both yourself and your employer.

• Follow capitalization rules– First word in a sentence– Names of people, countries, companies, etc.– Names of months and days of the week– Titles in a person’s name

Use Proper Grammar and Punctuation

• Follow punctuation rules– Period at end of sentences.– Commas to join two independent clauses.– Quotation marks to enclose exact words of a

speaker.– Always place periods and commas inside

quotation marks.

Writing Titles Correctly

• Dr. Curtis Schultz OR Curtis Schultz, M.D.• Use either Dr. or M.D., but never both• Same rule for D.V.M., D.O., D.D.S., etc.

Use Proper Grammar and Punctuation

• Follow punctuation rules– Period at end of sentences.– Commas to join two independent clauses.– Quotation marks to enclose exact words of a

speaker.– Always place periods and commas inside

quotation marks.

Confidentiality of Written Materials

• HIPAA establishes confidentiality standards• HIPAA = Health Insurance Portability Act• Patients must be able to see and obtain copies

of their records.• Patients set limits on who can see their

records.• Healthcare providers need written permission

to release patient records.

Patient Health Record (Chart)

• Must be neat and legible.• Use correct spelling and grammar.• Use objective observations.• Accurately “quote” patient’s words.• Sign with name and title.• Correct errors by crossing out with one line,

write “error” and initial.

Patient Health Records (Chart)

• Do not erase or obliterate.• Never chart before the event occurs.• Never chart for another person.• Do not leave blank spaces.• Kept for all patients/clients who receive care

in a health facility.• Property of the health facility.

Patient Health Record (Chart)

• Need written patient consent to release information• All entries in blue or black ink (allergies in red)• Parts of the chart may include:– Physician’s orders– Nurses notes– Graphic chart– Medication record– Progress notes– Reports and forms