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Documentation Style & Standards

 

The 4th edition is currently in its final stages of editing and we hope to have an update on the launch date soon.

Book of Style & Standards for
Clinical Documentation, 4th Edition


The 4th edition of the Book of Style & Standards for Clinical Documentation from the Association for Healthcare Documentation Integrity (AHDI) will be available in print and an online version. This widely acclaimed industry standards manual has long been the trusted resource for data capture and documentation standards in healthcare. The 4th edition delivers a streamlined and strategically reorganized flow of critical data, enhanced explanation of standards and practical application, robust examples taken from clinical medicine settings, and so much more.

What’s new in this edition?
  • Target audience expanded to include all health information management (HIM) professionals, information technologists (IT), and clinicians
  • Style rules adapted to speech recognition and electronic health record with in-depth guidance on editing
  • Updated to the most current standards with many new and expanded examples throughout
  • Expanded content in hematology, oncology, immunology, pathology, microbiology, genetics, and pharmacology
  • Updated content covering privacy and security
  • Additional frameworks for decision making New section on Facility Best Practices
  • Updated appendices, including more sample reports, expanded usage glossary of homonyms and sound-alikes, and a new lab reference
  • Specific guidance on appropriate use of brief forms, jargon, slang, and neologisms
  • Easy-reference classification tables including use of arabic versus roman numerals

 

 

The Book of Style for Medical Transcription, 3rd Edition

The 3rd edition of the Book of Style will continue to be available both in print and digital format.

 

View more details on the 3rd Edition here.

 

For more information, contact Member Services at ahdi@ahdionline.org or 800-982-2182.

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