Documentation Style Guide
Connect Care documentation tools promote charting made efficient by use of standardized building blocks. Various SmartTools (SmartLinks, SmartLists, SmartText, SmartPhrases, etc.) are used to create and then insert the building blocks into both 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.
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).
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.
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.
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.