HCA 130 Module 2 Proofreading and Revision as a Habit Example

Read It Again: Proofreading and Revising a Referral Letter

Student Name

Health Care Administration Program, Aspen University

HCA 130: Healthcare Writing and Communications

Instructor Name

Month Day, Year

Read It Again: Proofreading and Revising a Referral Letter

Most writing errors are caught by reading the document one more time. Yet in a busy clinic, letters and notes are often sent as soon as they are drafted. This paper treats proofreading and revision as a professional habit. It explains the difference between the two, presents a composite referral letter drafted with speech recognition software, lists the errors found and how they were fixed, and proposes a routine that fits a working day.

Revising and Proofreading

Revision and proofreading are different tasks. Revision looks at the whole document: whether the purpose is clear, the order makes sense, the content fits the reader and nothing important is missing. Proofreading looks at the surface: spelling, grammar, punctuation, numbers, names and format. Revision should come first, since there is no point polishing sentences that will be cut. Doing both in one pass usually means doing neither well.

The Draft

A medical assistant at a composite family clinic prepared a referral letter to a cardiology practice for a 58-year-old patient with new palpitations. The physician dictated it using speech recognition software, and the assistant's task was to review it before it was sent with the patient's records. The draft read smoothly at a glance, which is exactly why errors in dictated text are easy to miss.

What Speech Recognition Gets Wrong

Speech recognition saves time but introduces errors that look like real words. In a study of 217 dictated clinical notes, the error rate in raw speech recognition drafts was 7.4 errors per 100 words, falling to 0.4% after review by a professional transcriptionist and 0.3% in signed notes, yet 42.4% of signed notes still contained at least one error (Zhou et al., 2018). Review by a careful reader removes most errors but not all.

Errors Found

The assistant found eleven errors, grouped in the table by type.

The Most Dangerous Errors

Not all errors are equal. The sound-alike drug error, Celebrex for Celexa, could lead the cardiologist to think the patient took an anti-inflammatory rather than an antidepressant, which matters when assessing palpitations. The abbreviation QD is on lists of error-prone abbreviations because it can be misread as QID, four times daily. The number split by a space could be read as 1 or 18. These three errors could affect care, so they were checked against the record, not just corrected by guesswork.

The Revision Step

Before proofreading, the assistant asked whether the letter did its job. The reason for referral, evaluation of new palpitations with a resting heart rate of 118, was buried in the third paragraph. It was moved to the first sentence. A missing item, the patient's recent thyroid test result, was added from the record because a cardiologist would ask for it. Two sentences repeating the patient's history were cut. Structured formats used in clinical handoffs make the same move, stating the situation before the background; a systematic review found moderate evidence that the SBAR format improves patient safety, particularly in telephone communication (Müller et al., 2018).

A Proofreading Routine

The assistant used a routine that can be applied to any document. First, check every number, name, date and drug against the source record. Second, read the document aloud slowly, which catches missing and repeated words. Third, read it once more looking only for abbreviations and spell them out. Fourth, check format: header, address, signature and enclosures. The routine took six minutes for the one-page letter. Federal plain language guidance also recommends short sentences and common words, which make errors easier to spot on a second reading (Plain Language Action and Information Network, 2011).

Why Spell Check Is Not Enough

Spell check found none of the eleven errors. Weaks was flagged, but Celebrex, Patal and the split number were not, because they are either real words or treated as names. Grammar tools may catch the ECG show but not a missing phrase. Software is a first step, not a substitute for reading.

Protecting Privacy While Reviewing

Referral letters contain protected health information. The assistant reviewed the letter at a workstation facing away from the hallway, confirmed the receiving practice's fax number from the directory rather than from memory, and confirmed that only records relevant to the referral were attached.

Building the Habit

Habits form when the step is built into the workflow. The clinic added a review step to its referral process in the record system, so a letter cannot be sent until someone other than the author marks it reviewed. Staff keep a short list of the errors they find most often, such as sound-alike drugs and split numbers, and check for those first.

Reflection

The exercise showed that a letter that sounds right can still carry errors that change its meaning. Reading against the record, not only reading for sense, caught the errors that mattered most. Separating revision from proofreading also improved the letter more than proofreading alone would have, because the most useful change was moving the reason for referral to the top.

Proofreading Other People's Writing

Reviewing a physician's letter requires tact. The assistant did not rewrite the physician's clinical judgment; she corrected clear errors, confirmed facts against the record and flagged the drug name and the reorganized opening for the physician's approval. Asking rather than changing respects the author's responsibility for the content and builds trust in the review step.

Conclusion

Proofreading and revision are small tasks with large effects. A single referral letter drafted by speech recognition contained eleven errors, three of which could have affected care. A routine of checking facts against the record, reading aloud, spelling out abbreviations and checking format, preceded by a revision pass for purpose and content, caught all of them in six minutes.

References

Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: A systematic review. BMJ Open, 8(8), Article e022202. https://doi.org/10.1136/bmjopen-2018-022202

Plain Language Action and Information Network. (2011). Federal plain language guidelines. https://www.plainlanguage.gov/guidelines/

Zhou, L., Blackley, S. V., Kowalski, L., Doan, R., Acker, W. W., Landman, A. B., Kontrient, E., Mack, D., Meteer, M., Bates, D. W., & Goss, F. R. (2018). Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists. JAMA Network Open, 1(3), Article e180530. https://doi.org/10.1001/jamanetworkopen.2018.0530