Wesley Health Management

Transcription

1 Wesley Health Management Wesley Health Management Typing Business Letter Set-out Guide Wesley Medical Reception Course Assessment Guide for Medical Letter Production

2 Introduction When you type a business letter, you create a lasting image of yourself and the business you belong to. The way you communicate on paper will alert your reader to your level of education, your personality and your level of professionalism. If you are working as a medical secretary or typist, the setting out of a medical letter, will reflect on the overall professionalism of the practice you belong to. Understanding medical terminology, both written and verbal is a skill that is mastered with practice! If you are not sure of a word, either leave it blank or ask the doctor for clarification. You will be amazed how quickly your skills will improve with plenty of practice. A good medical dictionary or spell check is also a highly recommended tool for medical typists. The basic principles for all types of letters will be the same. A good business letter is not just about the content of the letter. The way the letter is formatted and presented is extremely important. Business letter format and layout (An example letter is provided further down). 1. Letterhead or set out with name, address and contact details. 2. Date (full English date ie 5 December 2011) 3. Name and address (ie Referring Doctor. No need to put full stops or commas in the name and address) 4. Salutation 5. Subject heading (Patient Details usually in bold typeface - indented) 6. Body of letter 7. Complimentary close Golden Rule is:- Yours faithfully is used when the person s name is not known Yours sincerely is used when the person s name is known - always. Both faithfully and sincerely in lower case. Kind regards or Regards is a popular closure for a less formal letter. 8. Signature 9. Reference or Enclosure 10. Abbreviation "enc" 11. Abbreviation "c" or "cc" Wesley Health Management Version Page 2

3 Guide to business letter format and presentation Document should be typed and printed out on a quality printer. Use only white paper and black ink, or the letterhead of your practice. Lots of white space - margins 3cm or 3.5 either side. Single line spacing in sentences. Leave one to two lines between paragraphs. Leave three to four lines for the signature. Centre the letter on the page from the bottom and the top margins if required. Font and font size. Check to see if your practice has a corporate font which is preferred. A popular font is Arial or Calibri, size 11 or maybe 10 if you have a lot of content. (Today we are more used to size 9-10 font, once considered too small). Do justify the margins. Use punctuation to assist in understanding the content. Do use bold and indent for the patient details. Make sure the person s name is spelt correctly. Sample Doctor s Letter Following is a sample doctor s letter and a typed version which shows an acceptable format for a medical letter. Please refer, however, to the policies and procedures of your practice with respect to a particular style that is acceptable. Have a go! Practice makes perfect! Have a go typing the attached doctor s letter. At times, it may be helpful to take a big picture view of the letter and to try make sense of what the doctor is saying rather than try decipher individual words out of context. If you are not totally confident of a perfectly translated doctor s letter, it is best to type a draft copy of plain white paper rather than waste practice letterhead. It will help the doctor understand that your copy is in draft format by typing draft copy on the top left hand side. Wesley Health Management Version Page 3

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6 8 November 2011 Dr Bill Jones Total Medical Care Services 8 Cambridge Drive STARLIGHT BAY WA 6123 Dear Bill Re : Stephen MARSDEN dob Kenny Street WARWICK 6052 Employer: Clear Craft Industries DOI Claim #Y94723 Thank you for asking me to review Stephen for a second opinion and for the enclosed letters from both Bernie Jones and Brian Smith. I will not go laboriously through the whole of Mr Marsden s history other than to say on 6 th July 1999, he was sitting down on the floor in order to pull on a lever a short distance off it. Mr Marsden was sitting hunched forward as he attempted to pull on the lever, which he was unaware was jammed. The following morning he had severe lower lumbar spinal pain for which he has had conservative management since. This has included physiotherapy, both active and exercise based, acupuncture and a variety of analgesics and NSAIDS. Mr Marsden has had an MRI scan which shows a degenerative disc at L5/S1 and a positive discogram at that level. On examination today I found Mr Marsden to be quite genuinely stiff and sore. He was only able to flex to his knees. Surprisingly straight leg rising to only ten degrees produced severe spasm of the lumbar spine as did a request to dorsal flex his toes. I could not find any neurological signs to account for this pain. I think that fusion at L5/S1, using pedicle screws and rods with a postero-lateral bone graft would be my preference. This is a particularly attractive option given his very positive discogram and MRI findings as both are highly suggestive in confirming this level as the site of pain generation. I ve discussed the chances of success and told him they are in the order of 80/20 in the positive that he would succeed. As you know pain situations are often more complex and success is not guaranteed. Many thanks and best wishes JOHN PARKS FRACS Wesley Health Management Version Page 6