Written Communication Skills

1. Written Communication Skills

2. 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.

3. 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

4. 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.

5. 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.

6. 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

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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