Introduction

The efforts to standardize clinical documentation are gaining momentum with collaborations such as the Health Story Project. The advancement of speech recognition, transcription and electronic documentation technologies provide the platforms to produce standardized documentation without placing additional burdens on clinicians. Computer assisted coding (CAC) solutions are benefactors of this effort which, in turn, also benefits HIM departments. All HIM professionals know that more consistent and complete clinical documentation increases the accuracy of coding results, and AHIMA is strongly supporting initiatives to set documentation standards. We will discuss these efforts and present examples of clinical documentation in standardized form. Today, CAC technology has been applied to both standard and non-standard document types. From this experience, we discuss best practices for initial implementation and ongoing maintenance of CAC solutions for both standard and non-standard documents.