Documentation’s Finer Points
By Selena Chavis
For The Record
Vol. 31 No. 6 P. 14
The latest edition of AHDI’s guidebook aims to standardize clinical documentation style.
The Association for Healthcare Documentation Integrity (AHDI) will release the fourth edition of its Book of Style this summer with an expanded focus. Previously directed at medical transcription standards, the target audience for the new manual encompasses all HIM professionals, information technologists, and clinicians.
According to Laura Bryan, MS, CHDS, AHDI-F, vice president of MedEDocs and chair of the style guide development team, the hope is that the manual will become health care’s trusted guidebook for data capture and documentation standards.
“The new style guide is intended to be an industry resource focused on establishing best practices in documentation,” Bryan says. “Because it lends consistency and presents the ideal way to convey information, it makes clinical documentation more useful and reduces the cognitive burden on physicians.”
Along with an expanded focus, the new manual also gets a new name: Book of Style & Standards for Clinical Documentation, 4th Edition, known colloquially as BOSS4CD, which represents how it encompasses much more than just traditional transcription standards—the primary focus of previous editions.
“The goal is to offer a universal guide for consistency for all methods of documentation creation, including clinician-created documentation directly within the EHR, front-end speech recognition, and back-end speech recognition,” says Stacy Lehto, CHDS, senior health care documentation quality analyst with Spectrum Health and a member of the BOSS4CD development team. “BOSS4CD offers standards that fill all these scenarios.”
Karen L. Fox-Acosta, CHDS, AHDI-F, a quality documentation consultant, points out that in today’s health care climate, patient health information is provided through a wide variety of documentation activities including but not limited to the following:
• clinician self-entry;
• EHR point-and-click with drop-down menus;
• expandable text templates;
• front-end self-edited speech recognition;
• back-end speech editing; and
• traditional dictation/transcription.
“A primary goal at the start of the BOSS4CD project was to put documentation standards in an easily consumable form for a broader audience of users,” Fox-Acosta explains, emphasizing that the ultimate goal is to create an accurate representation of all patient encounters. “It is important to recognize that the fourth edition, while presenting authenticated style procedures, is meant to be used as a tool toward standardizing communication in patient documentation, so all audiences are on the same page of meaning and intent.”
AHDI, which published its first style manual in the early 1980s, has since dedicated its work to developing, promulgating, and applying standards for communicating clinical and technical communication. Bryan notes that BOSS4CD delivers a standardized approach to documentation that is relevant for today’s clinicians through guidelines that outline best practices for usage and language composition, visual composition, orthography, and typography in hopes of reducing ambiguity, eliminating confusion, and promoting uniformity.
While standardization is the goal, Bryan points out that keeping documentation “unique to patient” was also central to the mission.
In its expanded form, Fox-Acosta suggests that “BOSS4CD moves away from basic grammar and punctuation and presentation ‘style’ issues and delves into accurate presentation of information using verified, standardized methodology to convey current data and reflect the patient’s story that is usable for any reader.”
The new edition reorganizes all content into topical sections and chapters with complete redrafts of content sections throughout, including new medical specialty chapters. Users can expect a more detailed, comprehensive explanation of content and the rationale for particular standards and styles as well as improved application examples.
BOSS4CD also includes complete chapters dedicated to medical record types and formats, including turnaround times; medical record privacy, security, and integrity; and amending and modifying patient records. Additionally, the guide addresses trends and drivers impacting the industry as well as the potential impact of emerging technologies on a specific standard.
Bryan notes that BOSS4CD helps the industry overcome a number of documentation variability challenges that are particularly significant.
Use of Gender Pronouns
Fox-Acosta points out that for clinicians who speak English as a second language, gender pronouns can present notable challenges because some languages do not use them while others are very gender specific.
There are other pronoun concerns as well. “With transgender or gender-reassignment transitioning patients, gender pronouns can be easily misunderstood,” she says. “Another issue relates back to basic demographics to ensure correct patient selection, [as] given names do not always accurately portray gender identity.”
Lehto emphasizes the importance of establishing facility policies to address patients’ pronoun preferences. “There are several areas where providers need to be sensitive to the needs of the patient. The BOSS4CD recommends referencing GLAAD or other websites that are advocates for gender issues,” she says.
Abbreviations present a “huge area of concern for health care documentation specialists in practice and in student training,” according to Fox-Acosta, who notes they can have different meanings based on specialties and facilities. In addition, clinicians often make up their own.
To get out in front of this problem, Lehto says facilities should establish policies regarding abbreviations and adopt standards.
Bryan notes that regional terms present significant challenges for both humans and technologies. For example, the state of Florida uses of the term “Baker Act” to refer to involuntary institutionalization or examination of an individual. Because the terminology is specific to the state, information can get lost in translation when the term is used or shared across state lines.
Fox-Acosta points out that where a clinician is educated can also present standardization challenges. “Phrases and references of the same problem or disease process can vary dependent upon where a clinician went to school,” she says.
Dates and Times
Dates and times should be as precise as possible in order to accurately give a patient’s history, Lehto says, adding that actual dates are preferable to the use of “today” or “yesterday” for the purposes of documentation. “Copy-forward and copy-paste will not accurately reflect a history if ‘today’ is continually pulled forward,” she points out.
“This is an area that is essential to get correct but often difficult to ascertain when clinicians are documenting under stressful circumstances, emergencies, fatigue, or literal service that extends from one day to the next such as midnight time stamps,” Fox-Acosta says. “Many billing practices are based on dates and times so these must be accurate or left blank if unsure. As well, dictation and documentation time stamps are also crucial as medicolegal references and must be kept accurate.”
Fox-Acosta recommends avoiding the use of special characters because not all technology systems recognize them.
“In many cases, special characters are lost when interfaces are deployed, and the resultant text in the patient report is blank,” she says. “In addition, some technology systems see special characters as prompts or codes to act upon, and this can disrupt the intended meaning as well as workflow if a document is held up or sent to some unexpected place within the technology platform.”
While Lehto acknowledges that templates can be useful in making sure all required headings and information are contained within specific work types, she cautions that health care professionals can become too reliant on them, a situation that can lead to poor editing of negative or positive findings.
Fox-Acosta notes that BOSS4CD standards point to uniform construction of templates to ensure accuracy. In addition, they should be built with variables in mind to allow for incorporation of discrete evidence and data when needed.
The Value of National Documentation Standards
Bryan believes national documentation standards are of great benefit on numerous fronts. In terms of single sourcing information to improve portability, she points out that “knowing the standard and applying it across the board can help with the normalization effort,” which improves data aggregation, analysis, and exchange.
It also provides a solid foundation to support emerging technologies such as artificial intelligence.
According to Fox-Acosta, many facilities and HIT vendors create standards or best practices to use in their own quality programs. This results in information becoming siloed, making it nearly impossible for it to be communicated with integrity across systems.
“AHDI is providing a tool that will combat that problem,” she says, pointing out that effective communication is dependent on all stakeholders speaking the same language. “BOSS4CD is a step in that direction, pulling verified resources into a one-stop source for clinical documentation standards and style. On the national scale, in order for interoperability to be effective and maintain the necessity of accurate and complete patient care records, information shared must be understood by all readers as carrying the same intent and meaning.”
Because some organizations will still want to use their own proprietary standards, BOSS4CD is designed as a validated resource to use directly or as a base to build best practices. “Where we have seen negative impact is when standards or best practices are developed based on individual clinician habits or built from subjective choices rather than authenticated data,” Fox-Acosta says. “Standards eliminate idiosyncratic pitfalls and build integrity of communication across all sources.”
Bryan says documentation standards also deliver significant value to clinicians and patients. “Because [standards] lend consistency and present the ideal way to convey information, they reduce cognitive burden on physicians. They become accustomed to a certain way of displaying that information,” she explains, adding that reduced variability improves the safety and overall delivery of care to patients. “Clear and unambiguous written communication promotes consistency and accuracy, improved usability, and readability.”
For HIT professionals, Bryan points out that the style guide provides the backbone of their work, simplifying how they approach programming.
Challenges to Adoption
To extract the greatest value from national documentation standards, the industry must have a path forward that promotes widespread adoption. Bryan suggests that one of the greatest hurdles is educating the industry about style’s impact as it relates to improved care delivery and performance improvement.
Lehto agrees, noting that AHDI must get out in front of the new style guide release to promote the expanded focus. “We offer so much more as far as document integrity. One of our earliest discussions was who would be reading our book. Would it be only health care documentation specialists? Will it be educators? Will it be HIM departments and/or physicians? Who do we market this to? We need to emphasize how AHDI has evolved to encompass all methods of report creation and advocate for clear, concise, quality reports that tell the patient’s story properly,” she says.
Fox-Acosta adds that AHDI also faces credibility challenges. “Our workforce and the resources we utilize have always been on the forefront of an accurate and complete documentation of the patient’s story, [but] the health care industry has yet to fully grasp the discrete nature of our contribution to the entire workflow beyond clinician signature. Having a resource that we can use in our daily work is essential to that goal,” she says.
In addition, Fox-Acosta points out that AHDI now has a much broader audience to reach—HIM professionals, HIT programmers and vendors, health care documentation specialists, editors, auditors, students, coders, clinical documentation improvement specialists, revenue cycle specialists, clinicians, C-suite decision-makers, and more. Each of these professions requires a different message, she says, because the value proposition is different for each one.
Bryan emphasizes that once adoption becomes mainstream, it will be imperative that there is consistent implementation of style across platforms.
While the challenges are significant, they are not insurmountable, Lehto says, adding that “national standards are very important in giving credibility to our industry. A set of guidelines creates a standard for medical records, regardless of geographic location. It is important to have a uniform guide for quality medical records regardless of the organization.”
— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.