This session will discuss the value and benefits of documentation standards as described by standards developing organizations. Examples of relevant standards will be provided. The speakers will demonstrate how the consistent use of style in the healthcare record promotes clear communication, contributes to patient safety, and improves information exchange, integration, and aggregation. Participants will understand how applying standards of style to EHR templates, drop-down text, and data dictionaries reduces the need for data normalization and improves results from natural language processing (NLP) and artificial intelligence (AI). Attendees will also gain valuable insight into the importance of applying style standards to human-readable text to reduce physician burden.
After this session, attendees should be able to:
- Identify the purpose of style standards related to clinical and technical information.
- Recognize the value of style standards to improve usability and communication among clinicians and to enhance patient safety.
- Understand the value of a single-source reference tool for writing clinical and technical information.
- Distinguish formatted vs non-formatted clinical data.
Laura Bryan, MS, CHDS, AHDI-F, Vice President, MedEDocs
Susan D. Dooley, MHA, CMT, AHDI-F, Board Member, Association for Healthcare Documentation Integrity
Participation in this event has been pre-approved for 1 hour of credit on your CAHIMS/CPHIMS application for recertification. All hours must be self-reported in your HIMSS online record.