Documentation Style & Standards

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 (eg, policymakers, health information managers, programmers, template designers, informaticists, editors, auditors, clinicians, and scribes).

The BOSS4CD is a curated, convenient reference for anyone working in clinical documentation (eg, policymakers, health information managers, programmers, template designers, informaticists, editors, auditors, clinicians, and scribes). It is a compilation of relevant standards culled from numerous standards developing organizations and adapted to current technology. Style standards are intended to improve communication; they ensure consistency within a document and across multiple documents and improve readability and comprehension.

What’s New in this Edition?

• Expanded target audience to include all health information management (HIM) professionals, information technologists (IT), and clinicians
• Style rules adapted to speech recognition technology and the electronic health record with in-depth guidance on editing in these environments
• Expanded content in the areas of hematology, oncology, immunology, microbiology, pathology, pharmacology, and genetics
• Updated content covering privacy and security
• Frameworks for determining appropriate use of brief forms, jargon, slang, and neologisms
• Facility best practices related to:
  • Normals and standard templates
  • Clinical documentation capture
  • Content importing technologies (copy and paste)
  • Gender pronouns
• More detailed table of contents at the beginning of each chapter
• Updated appendices, including new sample reports, expanded glossary of homonyms and sound-alikes, and a new reference section for common laboratory studies
• Easy-reference table of classification systems indicating arabic versus roman numerals as well as uppercase versus lowercase letters used in subclassifications
• Updated, professionally drafted index

Download: Sample pages

Clarifications and Corrections to Book of Style & Standards, 4th edition

Ordering BOSS4CD

Printed Book (spiral bound) – NOW AVAILABLE!

ISBN: 978-0-935229-64-6

BOSS4CD is available as a spiral-bound printed text. Long requested by users, spiral binding advantages include pages that turn easily, lay flat and stay put, and open a full 360 degrees.

Digital License (ePub) – NOW AVAILABLE!

ISBN: 978-0-935229-54-7

The digital BOSS4CD is available in a searchable format via VitalSource Bookshelf. Access your eBook 24/7 via the Internet or download the Bookshelf app (free) to your device for offline access anytime. The eBook format adapts and displays content correctly, no matter which device you’re using—iOS, Android, Kindle Fire, Mac, PC, or Chromebook. Search the Table of Contents, sections/subsections, and by ke

yword(s) to find an important professional standard easily. Highlight text and add notes or bookmarks for quick reference. New Bookshelf features allow you to create digital flashcards, which is particularly helpful to students. You can even 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.

View a quick tutorial on how to navigate the Book of Style in VitalSource Bookshelf.

AHDI VitalSource Refund Policy

No refund will be given on any digital books purchased through VitalSource after 14 days from the date of purchase. We provide comprehensive information about our products and also offer free consultations by email or phone prior to purchase.

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