1、Designation: E 2117 06An American National StandardStandard Guide forIdentification and Establishment of a Quality AssuranceProgram for Medical Transcription1This standard is issued under the fixed designation E 2117; the number immediately following the designation indicates the year oforiginal ado
2、ption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon (e) indicates an editorial change since the last revision or reapproval.1. Scope*1.1 This guide covers the establishment of a quality assur-ance program f
3、or dictation, medical transcription, and relatedprocesses. Quality assurance (QA) is necessary to ensure theaccuracy of healthcare documentation. Quality documentationprotects healthcare providers, facilitates reimbursement, andimproves communication among healthcare providers, thusimproving the ove
4、rall quality of patient care. This guideestablishes essential and desirable elements for quality health-care documentation, but it is not purported to be an exhaustivelist.1.2 The QA personnel for medical transcription should havean understanding of the processes and variables or alternativesinvolve
5、d in the creation of medicolegal documents and anunderstanding of quality assurance issues as they pertain tomedical transcription. Qualified personnel include certifiedmedical transcriptionists (CMTs), quality assurance profes-sionals, or individuals who hold other appropriately relatedcredentials
6、or degrees.1.3 The medical transcriptionist (MT) and QA reviewershould establish a cooperative partnership so that the reviewoutcomes are objective and educational to include correctiveactions and remedies. Policies should be developed to mini-mize subjective review, which can lead to forceful imple
7、men-tation of one style at the expense of other reasonable choices.Objective review, including an appeals process, should followorganizational standards that have been agreed upon by the fullteam of QA personnel, MTs, and management staff.2. Referenced Documents2.1 ASTM Standards:2E 1762 Guide for E
8、lectronic Authentication of Health CareInformationE 1902 Specification for Management of the Confidentialityand Security of Dictation, Transcription, and TranscribedHealth RecordsE 1959 Guide for Requests for Proposals Regarding Medi-cal Transcription Services for Healthcare InstitutionsE 2344 Guide
9、 for Data Capture through the Dictation Pro-cessE 2502 Guide for Medical Transcription Workstations2.2 Other Documents:Public Law 104191 Health Insurance Portability and Ac-countability Act of 1996 (HIPAA)3Joint Commission on Accreditation of Healthcare Organiza-tions (JCAHO) Do Not Use Abbreviation
10、 List43. Terminology3.1 Definitions:3.1.1 author, nthe person(s) responsible and accountablefor the creation, content, accuracy, and completeness of eachdictated and transcribed event or health record entry.3.1.2 back-formation, na verb formed from a noun, forexample, dialyze (verb) from dialysis (n
11、oun).3.1.3 concurrent review, nquality review of transcribedreports performed while listening to dictation and comparingtranscribed document content. Concurrent review is generallyperformed before reports are delivered to a patients record,either in print form or electronically, and before they are
12、madeavailable for author signature.3.1.4 corrective action, na process used to rectify asituation or problem.3.1.5 medical transcription, nthe process of interpretingand transcribing dictation by physicians and other healthcareproviders regarding patient assessment, workup, therapeuticprocedures, cl
13、inical course, diagnosis, prognosis, etc., intoreadable text, whether on paper or on computer, in order todocument patient care and facilitate delivery of healthcareservices. (AAMT Book of Style; E 1959)3.1.6 originatorsee author.3.1.7 quality assurance audit, nexamination and reviewof transcribed d
14、ocuments to verify accuracy of work type,1This guide is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.15 on HealthcareInformation Capture and Documentation.Current edition approved Oct. 15, 2006. Published November 2006. Or
15、iginallyapproved in 2000. Last previous edition approved in 2000 as E 2117 00.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page on
16、the ASTM website.3Available from U.S. Government Printing Office, Superintendent of Dcou-ments, 732 N. Capitol St., N.W., Mail Stop: SDE, Washington, D.C. 20401. See alsohttp:/aspe.hhs.gov/adminsimp.4Joint Commission on Accreditation of Healthcare Organizations: www.jca-ho.org.1*A Summary of Changes
17、 section appears at the end of this standard.Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.patient and author identification, and that dictated content wasappropriately transcribed and edited, with findings communi-cated to and revi
18、ewed with appropriate staff. A quality assur-ance audit is generally performed after reports are delivered toa patients record and may also be called a retrospectivereview.3.1.8 quality assurance for medical transcription, ntheprocess of review that is intended to provide adequate confi-dence that d
19、ictated patient care documentation is transcribed ina clear, consistent, accurate, complete, and timely manner andthat it satisfies stated or implied requirements for dictated andtranscribed documentation of patient care. A quality assuranceprogram may also be called a quality improvement program.3.
20、1.9 remedies, nalternatives for correcting a situation orproblem at the MT or author level.3.1.10 retrospective audit, nquality review of transcribedreports performed after documents have been released forauthor signature and delivered to a patients record. The voicefile may no longer be available f
21、or comparison with thetranscribed documents. It is preferable that retrospective auditbe carried out with voice file.3.1.11 stat, adjof high priority, or urgent, such as dicta-tion requiring immediate transcription and delivery.3.1.12 text expander, ncomputer software that allows afew letters or sym
22、bols to be expanded to a phrase or sentencein order to enhance productivity.3.1.13 turnaround time, nelapsed time beginning with theavailability of dictation or voice file for transcription andending when the transcribed document is delivered for authen-tication. (E 1959)3.1.14 verbatim transcriptio
23、n, ndocumentation that hasbeen transcribed exactly as dictated, without editing for accu-racy, consistency, completeness, or clarity. See The AAMTBook of Style5for additional information.3.2 Acronyms:AAMT American Association for Medical TranscriptionCMT Certified Medical TranscriptionistHIPAA Healt
24、h Insurance Portability and AccountabilityAct of 1996MT Medical Transcriptionist; Medical TranscriptionQA Quality AssuranceRFP Request(s) for Proposals4. Significance and Use4.1 This guide lists the essential components of a qualityassurance program/quality improvement program for medicaltranscripti
25、on and is applicable in all work environments. Itdescribes factors that should be considered when evaluating theindividuals and processes responsible for producing patientcare documentation and for establishing procedures to addressand resolve problems that may arise in dictation and transcrip-tion.
26、 It clarifies who has the authority to make decisionsregarding transcription style and editing and to resolve con-flicts.4.2 This guide may be used to develop a quality assuranceprogram for individual medical transcriptionists, medical tran-scription departments within healthcare institutions, medic
27、altranscription businesses, and authors of dictation. A qualityassurance program verifies the consistency, correctness, andcompleteness of dictation and transcribed reports, including thesystematic identification and resolution of inaccuracies andinconsistencies, according to organizational standard
28、s. Merelyproofreading reports is not equivalent to a quality reviewprocess, which should involve comparison with the dictation atleast part of the time and review for meaning of content all ofthe time.4.3 Quality is fundamental to the patient record, and clear,complete, accurate patient care documen
29、tation helps controlthe rising cost of health care and contributes to patient safety.The quality of the final report is the responsibility of both theauthor and the medical transcriptionist. It is the result ofteamwork between the person dictating and the individualtranscribing. It should be noted t
30、hat while production standardsare important, their value is diminished if quality is lacking.Likewise, transcribing dictation verbatim may not result inquality documentation or clear communication. It is the tran-scriptionists responsibility to recognize, identify, and reportvoice files that lack ac
31、curacy, completeness, consistency, andclarity for corrective action.5. Dictation5.1 There are four areas that should be addressed with everynew author providing dictation, and with all authors at regularintervals, particularly when changes occur in policies, staffing,or equipment, or a combination t
32、hereof. These four areas are(1) education and orientation, (2) document and patient iden-tification processes, (3) dictated content, and (4) confidentialityand security (See Guide E 2344).5.2 Quality assurance of medical transcription begins withthe author of the dictation. The quality of transcribe
33、d docu-ments is dependent on the quality of dictation. Authors shouldbe educated and oriented in creating a timely, accurate, andunderstandable dictated report, with emphasis on avoiding theuse or overuse of abbreviations, acronyms, back-formations,coined terms, jargon, profanity, short forms, and s
34、lang. Accu-racy and completeness of document content are the responsi-bility of the author.5.3 Education and Orientation:5.3.1 Education and orientation of authors should include anoverview of the report generation process, location and properuse of equipment, report types and arrangement of content
35、,proper identification of the patient, and turnaround time re-quirements. Potential problems and procedures for their reso-lution should also be addressed.5.3.2 To ensure accuracy, completeness, and consistency ofdocumentation, regulatory requirements and organizationalpolicies and guidelines for re
36、port formats and organization ofcontent should be followed.5.3.3 A mechanism for feedback should be provided to theauthor regarding the dictation or the process to ensure that theauthor is aware of any problems that may preclude clear,accurate documentation or impede timely transcription. Thisinclud
37、es the choice of a quiet and secure area in which todictate; adequate preparation before beginning the dictationprocess; self-identification by spelling name and providingidentification number; proficiency in the use of necessary5Tessier, Claudia, The AAMT Book of Style for Medical Transcription, Am
38、ericanAssociation for Medical Transcription, 1995 (print), 1997 (CD-ROM).E2117062equipment; and confirmation of patient identifiers by enteringnumbers correctly, providing pertinent dates, and accuratelyspelling patient names upon accessing the dictation system.Authors of healthcare documents should
39、 also correctly spellnew or unusual terminology and medications as necessary toensure accurate transcription. Authors should identify referringphysicians, consultants, and those receiving courtesy copies,providing spelling, complete addresses, or other informationthat will facilitate delivery.5.3.4
40、Priority of work types relative to dictation time andtranscription turnaround time should be included as part of theorientation process. Turnaround time should be defined andexpectations clarified. See Guide E 1959 for the definition ofturnaround time related to requests for proposals and out-source
41、d transcription.5.4 Document and Patient Identification Process:5.4.1 Instruction should be provided on the document iden-tification process, for example, how to access the dictationsystem, how to indicate a priority dictation using the appropri-ate dictation prompts, how to separate multiple report
42、s in onesession or call-in, and how to recognize technical problems andnotify designated personnel, indicating from what location thesystem is being accessed and the nature of the technical issue.5.4.2 The author of dictation should be aware that accurateand complete input of author identifiers, wor
43、k type, and patientidentifiers promotes efficiency and enhances turnaround time.Dictation of several reports on multiple patients using only onepatient identifier limits the ability to track and locate specifiedpatient documentation. Entry of incorrect work types often willdelay transcription of sta
44、t or high-priority reports (See GuideE 2344).5.5 Dictated Content:5.5.1 In order to document that the standard of patient careand all documentation requirements were met, authors shouldbe aware of risk management issues when dictating. Authorsshould adhere to standardized organizational requirements
45、 forrecommended or required report formats and order of contentsto facilitate communication among healthcare providers andenhance patient safety.5.5.2 Content should be free from asides, profanity, deroga-tory, and other inappropriate comments. Such comments maybe called to the attention of risk man
46、agement personnel.5.5.3 Content should not include extensive use of abbrevia-tions that obstruct communication. Authors should be awarethat, when transcribed, abbreviations, acronyms, short forms,jargon, coined terms, and back-formations may be expandedaccording to organizational policy or regulatio
47、ns. See JCAHODo Not Use Abbreviation List.5.5.4 Content should not include any specific references thatidentify the patient. See Guide E 1902.5.6 Confidentiality and SecurityConfidentiality and secu-rity of author and patient information should be emphasized.See Guide E 1902 regarding dictation and
48、transcription confi-dentiality and security.6. Transcription6.1 It should be the medical transcriptionists responsibilityto prepare patient care documents that are as accurate, com-plete, and timely as possible.6.2 Education and Orientation:6.2.1 Medical transcriptionists should strive to expand ski
49、llsand knowledge by regular participation in continuing educationand professional development activities. Relevant topics mayinclude clinical diagnosis and treatment, medical and profes-sional ethics, technology, professional practice and develop-ment, ergonomics, and industry trends.6.2.2 MTs should participate in the development of a QAprogram and be responsible for assisting others in assuringquality documentation.6.2.3 MTs should strive to prevent injuries by using soundergonomic techniques, thus facilitating the timely and accurateproduction of transcribed d
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