#16 NHA CCMA: Communication, Document Care, Management Systems, etc...

What forms can written communication take in healthcare?

Emails, letters, faxes, chat features.

Why is written communication important legally?

It is part of the permanent legal medical record.

What standards must written communication follow?

• Professional and respectful tone

• HIPAA privacy, security, and confidentiality

• Grammatically correct and error-free

• Reflects professionalism of MA and healthcare facility

What are key points when writing professional emails in healthcare?

• Use secure email software

• Check spelling and grammar

• Avoid jargon and slang

• Be concise and to the point

• Include subject line, salutation, closing with contact info

• Use polite, formal language (no texting style or abbreviations)

• Reference any attachments clearly

What is a common tool used to create business letters?

Templates that provide format and structure.

What components are included in a formal business letter?

Date, recipient address, salutation, body, complimentary closing, and letterhead.

When might certified mail be used for healthcare letters?

To confirm delivery of important messages, e.g., informing patients of concerning lab results or terminating patient-provider relationships.

What letter format is most common in healthcare organizations?

Full block format — all lines aligned to the left margin.

What are other letter formats used?

• Modified block: address and body left justified, other parts centered

• Modified block with indented paragraphs: address left justified, body centered with indents

• Simplified: left justified, no salutation or complimentary closing

What is a best practice before sending out formal letters?

Have another medical professional review the letter for accuracy and professionalism.

What are the key components of the communication cycle?

Sender, receiver, and message.

When is communication considered effective?

When the message is sent and received with the intended purpose.

What is therapeutic communication in healthcare?

A set of strong communication skills used to build positive rapport and relationships between healthcare providers and patients.

Why is therapeutic communication important?

It improves patient comfort, well-being, and encourages active participation in health decisions.

What does active listening involve?

Being mindful of what is said, how it’s said, and the intended meaning, showing engagement through body language and signals.

What are characteristics of active listening?

• Nonjudgmental attitude

• Positive body language

• Allowing time to process the message

What communication styles exist in healthcare?

Assertive, Passive, Aggressive, Manipulative.

Describe Assertive communication.

Ideal style—firm, direct, respectful tone, proper eye contact, and body language.

Describe Passive communication.

Quiet, soft voice, hesitant; may require a more assertive response.

Describe Aggressive communication.

Abrasive words and body language; loud, fast gestures; can feel intimidating; respond calmly.

Describe Manipulative communication.

One-sided, with ulterior motives; feels patronizing and is generally ineffective.

What are the three communication preference types?

Visual, Auditory, and Kinesthetic communicators.

Describe Visual communicators.

Prefer seeing info in writing or pictures; use facial expressions and hand gestures.

Describe Auditory communicators.

Rely on listening skills to understand the message.

Describe Kinesthetic communicators.

Prefer hands-on learning and physical engagement.

Why is recognizing communication styles important?

It allows tailoring responses for more effective communication.

What kinds of situations might require crucial conversations in healthcare?

Patients who are frustrated, in pain, financially struggling, or anxious about a terminal diagnosis.

What key skills are needed for handling challenging conversations?

Patience, active listening, empathy, and collaboration.

Why is empathy important in difficult conversations?

It helps patients gain understanding and acceptance during emotional times.

What must you ensure before discussing a patient’s health info with caregivers or surrogates?

That the patient has consented to releasing their health information.

How should medical assistants communicate with other healthcare professionals?

Professionally, respectfully, openly, and honestly, with a focus on quality patient care.

Do healthcare professionals need to be friends?

No, but they should always be friendly and professional.

Why is documentation important?

Because "if it isn’t documented, it didn’t happen" — documentation protects both patient and provider.

What details should be included in incident reports?

Date, time, persons involved, and specific details of the event or conversation.

How should you handle upset or frustrated patients?

Maintain professionalism, composure, and never respond with negative energy.

What communication technique helps reduce defensiveness?

Using “I” statements instead of “You” statements (e.g., “I understand…” vs. “You…”).

Why is it important to de-escalate challenging situations quickly?

To prevent the situation from becoming uncontrolled or more difficult to manage.

What strategies help de-escalate conflicts?

Open communication, letting the patient vent, active listening, professionalism, and respect.

When should a supervisor be involved in conflict resolution?

If the situation escalates or attempts at resolution are unsuccessful.

What are common barriers to effective communication?

Language differences, lack of personal boundaries, cultural differences, judgments, and stereotypes.

How can barriers affect communication?

They can hinder understanding and escalate conflicts.

Additional Tips for Challenging Conversations

• Ensure communication is free from distractions and interruptions.

• Set healthy physical and psychological boundaries.

• Use assertive communication that is tactful and courteous.

• Respond to verbal and nonverbal cues appropriately.

What is conflict management?

Managing situations where differences arise and no clear resolution is initially effective.

How can conflict be minimized in healthcare?

Through effective and respectful communication and having a clear resolution process in place.

What is the goal of conflict resolution in healthcare settings?

Achieving a win-win resolution where all parties feel heard and respected.

What are some effective conflict resolution methods?

• Letting the person express their concerns

• Practicing active listening

• Identifying possible solutions or outcomes

• Reaching a mutually satisfactory conclusion

Is conflict always about who’s right or wrong?

No — it's often about finding a respectful and mutually acceptable outcome.

How can understanding each party’s goals (not just their requests) help?

It promotes resolution by highlighting shared interests and similarities.

What should patients have if they are unsatisfied with care or outcomes?

A formal resolution process, including access to an unbiased person to review and suggest options.

What tool can be used to evaluate patient satisfaction and improve care?

Patient satisfaction surveys.

What is cause-and-effect analysis in healthcare?

Identifying potential risks (causes) and their outcomes (effects) to improve safety and satisfaction.

Why is cause-and-effect analysis important for healthcare organizations?

• Prevents incidents before they happen

• Improves patient satisfaction

• Ensures a safe environment for patients and staff

What is an example of a cause-and-effect safety check?

Walking through a facility to check for trip hazards like loose cords.

What is the goal of risk management in healthcare?

To ensure a safe environment for all — patients, staff, and visitors.

What does risk management involve?

• Analyzing the environment

• Identifying safety risks

• Taking steps to prevent harm

What are the three main components of the communication cycle?

Sender, Receiver, and Message.

When is communication considered effective?

When the message is sent and received with the intended purpose.

What is therapeutic communication in health care?

A communication style that builds positive rapport between providers and patients, improving comfort and engagement.

How does therapeutic communication impact the patient?

It encourages active participation in decisions, preventive care, and treatment choices.

What is active listening?

Listening that goes beyond hearing words—focusing on tone, body language, and intent.

Name 3 characteristics of active listening.

• Nonjudgmental attitude

• Positive body language

• Pausing to process what was said

What are some methods of communication in healthcare?

Oral, telephone, email, and text.

What are the 4 main communication styles?

1. Assertive – Direct, respectful, ideal in healthcare

2. Passive – Quiet, submissive, often needs assertive support

3. Aggressive – Loud, intimidating, best met with calm responses

4. Manipulative – Ulterior motives, often ineffective

What are the 3 main communication preferences?

• Visual – Learns through images and written info

• Auditory – Learns best by listening

• Kinesthetic – Learns through hands-on experiences

Why is it important to recognize communication styles and preferences?

To tailor your message for more effective communication.

What are “crucial conversations”?

Emotionally charged or difficult discussions, such as with frustrated patients, financial hardship, or terminal diagnoses.

How should crucial conversations be handled?

With empathy, patience, active listening, and collaboration.

What must you confirm before discussing patient information with caregivers?

That the patient has given consent to share information.

How should MAs communicate with the healthcare team?

With professionalism, openness, and respect for each member's role and knowledge.

What is the common goal of healthcare team communication?

Providing quality patient care.

What phrase emphasizes the importance of documentation in healthcare?

“If it isn’t documented, it didn’t happen.”

What details must be included in an incident report?

Date, time, persons involved, and detailed summary of the event.

Why is documentation critical in healthcare?

It protects both the patient and healthcare professional and ensures accurate records.

How should you respond to an upset or frustrated patient?

With professionalism, respect, and calm composure—never mirror negative energy.

What type of statements can reduce defensiveness?

Use “I” statements (e.g., “I understand…”), instead of “You” statements.

When should a problem situation be de-escalated?

As soon as possible, before it becomes uncontrolled.

What actions support de-escalation?

• Active listening

• Allowing the patient to vent

• Open, respectful communication

• Involving a supervisor if needed

• Setting healthy boundaries

What are common barriers to effective communication?

• Language differences

• Lack of personal boundaries

• Cultural differences

• Judgements and stereotypes

What is the goal of conflict resolution in healthcare?

To achieve effective, respectful, and win-win communication.

Name 3 methods of conflict resolution.

• Letting others express concerns

• Practicing active listening

• Finding mutually satisfying solutions

What should be available when patients are unsatisfied with the outcome?

A process for review by an unbiased person and alternative solutions.

How can understanding underlying goals help conflict resolution?

It shifts focus from demands to shared interests, promoting compromise.

What is cause-and-effect analysis used for in healthcare?

To identify and prevent incidents that could affect patient satisfaction or safety.

What is risk management?

A process that evaluates and improves the safety of the environment for everyone.

Give an example of a risk management strategy.

Walk through the facility to check for tripping hazards, like loose cords.

How does cause-and-effect analysis improve patient satisfaction?

By being proactive and reducing the likelihood of complaints or safety issues.

What are the two main sections of a patient’s medical record?

Administrative Section and Clinical Section

What is included in demographic data?

Name, address, birthdate, sex, gender, SSN, phone number, employment info

What are common administrative documents in a medical record?

• Notice of privacy practices

• Advance directives

• Consent forms

• Medical records release

• Correspondence from insurers, attorneys, or the patient

• Appointment, insurance, and billing information

What are components of the clinical section?

• Health history: chief complaint, present illness, PMH, family/social history, ROS

• Physical exam: assessment of body parts

• Allergies: all known allergies

• Medication record: detailed medication information

• Problem list: updated each visit

• Progress notes: every new patient interaction or phone call

• Laboratory data: lab reports

• Diagnostic procedures: ECG, spirometry, radiology, etc.

• Continuity of care: consults, hospital, home health, therapy docs

What types of documents support continuity of care?

• Consultation reports

• Home health care reports

• Therapeutic services

• Hospital documentation

What is the function of a Practice Management System (PMS)?

Manages scheduling, billing, insurance, patient registration, and administrative tasks.

What is the difference between an EMR and EHR?

• EMR: Digital medical record used within one healthcare organization

• EHR: Shared medical record accessible across locations by authorized users

How does EHR integration benefit patient care?

• Improves accuracy and efficiency

• Allows real-time lab and test result sharing

• Enhances continuity of care

How are PMS and EHR connected?

PMS handles the administrative side, while EHR manages clinical records. They often integrate to streamline care and workflow.

What types of data must health care providers report?

• Births and deaths

• Communicable/infectious diseases (HIV/AIDS, TB, STIs)

Why is reporting this health data important?

• Maintains vital records

• Tracks incidence (new cases) and prevalence (existing cases)

• Informs public health policies (e.g., helmet laws)

How do federal/state agencies use EMR/EHR data?

• To assess Medicare/Medicaid coverage and reimbursement

• To inform legislation and policy decisions on health care access and quality

What is CPOE?

A digital system where providers enter orders for medications, labs, scans, and referrals directly into the EHR.

What are the benefits of CPOE?

• Reduces human error (illegibility, transcription errors)

• Improves order accuracy and turnaround time

• Supports clinical decision-making

• Enhances communication and workflow