Book of Style & Standards for Clinical Documentation

This widely acclaimed industry standards manual has long been the trusted resource for data capture and documentation standards in health care. 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. Now, documentation specialists, editors, auditors, clinicians, informaticists, and scribes all take part in capturing the patient’s story. As such, this edition expands the previous audience of transcriptionists, editors, and transcription students to all participants in documentation capture and information exchange: documentation specialists, editors, auditors, health information managers, programmers, template designers, informaticists, clinicians, scribes, and policymakers.