The BOS is often called the ‘Bible’ of transcription rules and styles. Many students don’t use the Book of Style for Medical Transcription/Healthcare Documentation, and many aren’t even sure what is being talked about when it is brought up. We’re here to help you become a little more familiar with what it contains and how it can help you be a better transcriptionist.
The Association for Healthcare Documentation Integrity (AHDI), which published this style guide describes it as a “streamlined and strategically reorganized flow of critical data, enhanced explanation of standards and practical application, robust examples taken from clinical medicine settings, and so much more.”
More simply put, the Book of Style is a reference guide to the format preferences of medical transcription/healthcare documentation. It is a reference for grammar, punctuation, and usage. It helps explain these style preferences using practical medical samples. It also discusses some of the current and future trends that will affect our industry.
As you know, the first style reference at any job is ALWAYS the client specifics. They will have rules and formats particular to their organization that must be followed whether they are standard or not. However, these specifics are never all-inclusive. For any point of style not covered by those specifics, your first reference should be the Book of Style. Most jobs will expect you to be familiar with it and to adhere to it. Many employers will expect that you have access to it as a reference, which they may or may not provide.
The BOS is broken down into 5 main sections, which contain a large quantity of information. The BOS is invaluable as a reference guide for doing day-to-day transcription.
This section offers a general overview of medical documentation basics. Topics such as document types, formats, turnaround times, editing, and privacy issues are covered here.
This section is divided into chapters four to nine covering everyone’s favorite topics: grammar, usage, punctuation, capitalization, plurals and possessives, and abbreviations. It is very clear early on to an MT/HD that doctors are forming their dictations while reading their own notes, lab reports, and prior documents. They are also often distracted by office personnel, phones, lunch, etc. They are summarizing and tying things together as they think it through themselves in a busy office setting.
Because of this, they are not visualizing the page or paying close attention to grammar standards. They leave that to our expertise. This results in many statements that do not easily lend themselves to the application of standard grammar rules. While we can easily edit “the patient were admitted”, it isn’t so easy to clearly break up and transcribe a run-on sentence that goes on for six lines before Dr. Verbose takes a breath. Studying the components of language at the base level can help us decide how to deal with the phrases we hear in our sound files when we can’t just rephrase the whole thing.
“There is arguably no more critical information recorded and relied upon than the numeric values that represent a wide variety of indicators for both cause and effect in managing disease.” The three chapters of this section cover the basics of numeric references to help ensure that values in the record are easily understood by all readers.
If you want to know how to transcribe labor stages or heart sounds, how would you decide which of the above chapters to look at? No generalized grammar or numeric topic readily addresses these types of questions, but they must also be formatted in a standard way so that they are clear to all recipients of the record. This information is found in the twelve chapters of section four and is related to unique topics and quirks of individual specialties.
This section discusses a bit about the history of the industry and the evolution of some of the standards, as well as the future of where our industry is headed.
These include sample reports, AHDI’s Statement on Verbatim Transcription (guidelines and where it is going in the future), a glossary of sound-alike terms, model job descriptions, industry abbreviations, and an index.
All of the above topics are covered in the electronic BOS that you receive when you begin your MT/HDS course with CanScribe.
The Book of Style is one big book of information to be expected to be familiar with and adhere to on the job. The Book of Style is overwhelming to read all at once and difficult to search if you don’t know that something is there in the first place, how it will be worded, or where it might be tucked in.
Think of your BOS or eBOS like a dictionary. You wouldn’t really retain much if you started on page one and tried to memorize a language. Instead, go for a word of the day or, in this case, the topic of the day. To make it easier, perhaps start with everybody’s favorite, Section two and Section three. These are the most universal topics and the ones you should be most familiar with when you start working. When you are on the job, you can start picking topics on the specialties you work with the most.
If you wish to learn more about the AHDI, click here.