Documentation Style Guide

Connect Care documentation tools promote charting efficiency through use of standardized building blocks. Various SmartTools (SmartLinks, SmartLists, SmartText, SmartPhrases, etc.) are used to create and then insert the building blocks into progress and summative documentation templates. 

If design standards are not followed, then composites can end up looking clumsy and disorganized. Parts of a note, for example, may have font size, emphasis and formatting differences that make no clinical or conceptual sense. This can contribute to documentation that is difficult to skim and hard to understand.

Documentation style guides should be followed by all builders who in any way contribute to the building blocks or assemblies that help automate clinical documentation. This includes text that may appear as part of activities, navigators, order sets and other CIS objects. 

This section deals with general style guides applicable to all forms of documentation or text presentation. Subsections offer considerations for specific text automation tools.

Text

Font Face

The default font face selected for Connect Care is "Segoe UI". Other font faces must not be used without compelling reason (e.g., portrayal of formulas and symbols).

Font Size

The default font size is 11 points. Smaller sizes (9 points) can be used in tables that organize detailed information. The smallest size (8 points) can be used for citations and attributions. 

Larger sizes should not be used for headings and subheadings, which are instead distinguished by the font style.

Size should not exceed 12 points, to be used only for object titles.

Font Weight

Bold font weight should be used primarily for headings that reveal the structure of a documentation object (e.g., "History" in an admission note). A bolded test result is sometimes used to indicate abnormality or results that our outside an expected range. This should be done sparingly in clinical documentation, which should reflect what the clinician perceives to be a significant abnormality and not simply what a lab reports to be a few standard deviations from the mean. Accordingly, text automations should return test results in normal font weight, leaving the note authors to use bold font to draw attention to those specific findings that drive clinical decision making.

Font Style

Italics can be used for subheadings. They should not be used to mark up test results or flag parts of the text as being particularly significant. It may sometimes be appropriate to use italics to draw attention to direct quotations of patient remarks or instructions embedded in a documentation object.

Underline should be reserved for activity and internet links. These are often automatically added by Epic build editors. It is best to not confuse users by using underline for other purposes.

Dates and Times

Alberta Health Services has adopted ISO (International Organization for Standardization specification 8601) formatting for dates and times. These ensure unambiguous representation of time instances and intervals (e.g., YYYYMMDD or YYYY-MMM-DD). However, some adjustment was needed when working with Epic support for international date and time formats. The following formatting is configured as a standard in Connect Care and should be followed in all documentation tools in order to avoid end-user confusion or error.

Date

Time (24 hour format)

Abbreviations

In general, abbreviations and acronyms should not be used in text automations, such as SmartPhrases, SmartLinks and SmartText. The rationale for abbreviation use in hand-written documentation does not pertain in digital documentation and so considerations of clarity and avoidance of ambiguity trump any consideration of abbreviation familiarity. 

Hidden Instructions

It can be helpful to include instructions to users within documentation templates (e.g., SmartText, SmartPhrases). These may include internet links to additional resources or EpicACT links to additional sources of information within the chart. A special SmartList (ELT ID 10) can be used for this purpose. 

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