This session discusses the value and benefits of documentation standards as described by standards developing organizations. Examples of poor styles and relevant standards are provided. The speakers 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.
Laura Bryan, MS, CHDS, AHDI-F, Vice President, MedEDocs
Susan D. Dooley, MHA, CMT, AHDI-F, Board Member, Association for Healthcare Documentation Integrity
Resources discussed in the presentation: