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Documentation Style & Standards



The 4th edition is currently in its final stages of production and is anticipated to launch in mid-January.


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


The 4th edition of the Book of Style & Standards for Clinical Documentation (BOSS4CD) from the Association for Healthcare Documentation Integrity (AHDI) is available in print and digital versions. This widely acclaimed industry standards manual has long been the trusted resource for data capture and documentation standards in health care.


While the organizational structure is the same as the third edition, it marks a significant change from prior editions of The Book of Style in that it has been adapted to the current documentation environment within the electronic health record (EHR) and targets a much larger audience. The widespread implementation of the EHR, the prevalence of direct entry of information in real time by clinicians, and the extensive adoption of speech recognition technology (SRT) have increased the number of participants involved in clinical data capture. As such, this edition has been expanded to all participants in documentation capture and information exchange: policymakers, health information managers, programmers, template designers, informaticists, editors, auditors, clinicians, and scribes.



Thank You to Our Sponsors:

Tier 1:


Bryan Health


Spectrum Health


Tier 2:

H.I. Mentors, LLC

Hurley Makes It Happen

MDS of Kansas

MedRec Partners, LLC

WahlScribe, LLC

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
  • Standards updated to the most current available, with many new and expanded examples throughout
  • Expanded content in hematology, oncology, immunology, microbiology, pathology, pharmacology, genetics, radiology, diagnostic imaging, allergy, dermatology, and endocrinology
  • Updated content covering privacy and security
  • More detailed table of contents at the beginning of each chapter
  • Additional frameworks developed for effective decision making
  • New Facility Best Practices section developed to provide guidance and recommendations related to:
    • Chapter 21—Normals and Standard Templates
    • Chapter 22—Dictation Best Practices
    • Chapter 23—Policies for Content Importing Technologies
    • Chapter 24—Gender Usage
  • Updated appendices, including new sample reports, expanded usage glossary of homonyms and sound-alikes, and a new reference section for common laboratory studies
  • Easy-reference classifications table including use of arabic versus roman numerals and uppercase or lowercase letters with subclassifications.
  • Specific guidance on appropriate use of brief forms, jargon, slang, and neologisms
  • An updated professionally drafted content index
  • An updated itemized listing of specific standards that have changed


Ordering BOSS4CD

Printed Book (spiral bound)

The 4th edition Book of Style & standards is now available as a spiral-bound text. Long requested by users, spiral binding advantages include pages that turn easily, lay flat and stay put, and open a full 360 degrees.

Price (spiral-bound print copy): $75 Eligible Members/$100 Nonmember


order nowOrdering will be available soon


Digital License (ePub)
digital bos4

The BOSS4CD is available in searchable digital format via VitalSource Bookshelf. Access your BOSS4CD eBook via the Internet or download Bookshelf onto your device to access it offline. The eBook format will adapt and display content correctly, no matter which type of device you're using—iOS, Android, Kindle Fire, Mac, PC, or Chrombook. The eBook allows you to search the table of contents, sections/subsections, and by keyword(s) to find an important professional standard easily and effortlessly. Highlight text and add notes or bookmarks to reference them at any time. New Bookshelf features allow you to copy content and create digital flashcards, which is particularly helpful to students and those studying for their credentialing exam, and listen as an audio book using the built-in text-to-speech tool.


This is a must-have resource for students, educators, and all working professionals documenting patient care. Quality assurance coordinators and editors will find it an invaluable tool for providing BOSS4CD feedback to employees and trainees.


System Requirements:
For system requirements and detailed instructions on how to download Bookshelf to your computer or other digital device, visit Vital Source.



Digital Format (ePub)

180-day license

1-year license

Perpetual license

Eligible member price




Nonmember price





Once you purchase your digital copy of the BOSS4CD, you will receive an email with the link to Vital Source and a redemption code within 1 to 2 business days.

Ordering will be available soon



NOTE: Bundle pricing for both the print and digital formats is not available.


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 formats. 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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