1、Designation: E2117 06 (Reapproved 2011)Standard Guide forIdentification and Establishment of a Quality AssuranceProgram for Medical Transcription1This standard is issued under the fixed designation E2117; the number immediately following the designation indicates the year oforiginal adoption or, in
2、the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon () 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 for dictation,
3、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 overall quality o
4、f 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 alternativesinvolved in the creat
5、ion of medicolegal documents and anunderstanding of quality assurance issues as they pertain tomedical transcription. Qualified personnel include certifiedmedical transcriptionists (CMTs), quality assuranceprofessionals, or individuals who hold other appropriatelyrelated credentials or degrees.1.3 T
6、he 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 implemen-tation of on
7、e 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.1.4 This international standard was developed in accor-dance with internation
8、ally recognized principles on standard-ization established in the Decision on Principles for theDevelopment of International Standards, Guides and Recom-mendations issued by the World Trade Organization TechnicalBarriers to Trade (TBT) Committee.2. Referenced Documents2.1 ASTM Standards:2E1762 Guide
9、 for Electronic Authentication of Health CareInformation (Withdrawn 2017)3E1902 Specification for Management of the Confidentialityand Security of Dictation, Transcription, and TranscribedHealth Records (Withdrawn 2011)3E1959 Guide for Requests for Proposals Regarding MedicalTranscription Services f
10、or Healthcare InstitutionsE2344 Guide for Data Capture through the Dictation ProcessE2502 Guide for Medical Transcription Workstations2.2 Other Documents:Public Law 104191 Health Insurance Portability and Ac-countability Act of 1996 (HIPAA)4Joint Commission on Accreditation of Healthcare Organiza-ti
11、ons (JCAHO) Do Not Use Abbreviation List53. 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, forexamp
12、le, dialyze (verb) from dialysis (noun).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 e
13、lectronically, and before they are madeavailable for author signature.3.1.4 corrective action, na process used to rectify asituation or problem.1This guide is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.15 on HealthcareIn
14、formation Capture and Documentation.Current edition approved July 1, 2011. Published August 2011. Originallyapproved in 2000. Last previous edition approved in 2006 as E2117 06. DOI:10.1520/E2117-06R11.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Serv
15、ice at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.3The last approved version of this historical standard is referenced onwww.astm.org.4Available from U.S. Government Printing Office, Superintendent ofDcouments
16、, 732 N. Capitol St., N.W., Mail Stop: SDE, Washington, D.C. 20401.See also http:/aspe.hhs.gov/adminsimp.5Joint Commission on Accreditation of Healthcare Organizations: www.jca-ho.org.*A Summary of Changes section appears at the end of this standardCopyright ASTM International, 100 Barr Harbor Drive
17、, PO Box C700, West Conshohocken, PA 19428-2959. United StatesThis international standard was developed in accordance with internationally recognized principles on standardization established in the Decision on Principles for theDevelopment of International Standards, Guides and Recommendations issu
18、ed by the World Trade Organization Technical Barriers to Trade (TBT) Committee.13.1.5 medical transcription, nthe process of interpretingand transcribing dictation by physicians and other healthcareproviders regarding patient assessment, workup, therapeuticprocedures, clinical course, diagnosis, pro
19、gnosis, etc., intoreadable text, whether on paper or on computer, in order todocument patient care and facilitate delivery of healthcareservices. (AAMT Book of Style; E1959)3.1.6 originatorsee author .3.1.7 quality assurance audit, nexamination and reviewof transcribed documents to verify accuracy o
20、f work type,patient and author identification, and that dictated content wasappropriately transcribed and edited, with findings communi-cated to and reviewed with appropriate staff. A quality assur-ance audit is generally performed after reports are delivered toa patients record and may also be call
21、ed a retrospectivereview.3.1.8 quality assurance for medical transcription, ntheprocess of review that is intended to provide adequate confi-dence that dictated patient care documentation is transcribed ina clear, consistent, accurate, complete, and timely manner andthat it satisfies stated or impli
22、ed requirements for dictated andtranscribed documentation of patient care. A quality assuranceprogram may also be called a quality improvement program.3.1.9 remedies, nalternatives for correcting a situation orproblem at the MT or author level.3.1.10 retrospective audit, nquality review of transcrib
23、edreports performed after documents have been released forauthor signature and delivered to a patients record. The voicefile may no longer be available for comparison with thetranscribed documents. It is preferable that retrospective auditbe carried out with voice file.3.1.11 stat, adjof high priori
24、ty, or urgent, such as dictationrequiring immediate transcription and delivery.3.1.12 text expander, ncomputer software that allows afew letters or symbols to be expanded to a phrase or sentencein order to enhance productivity.3.1.13 turnaround time, nelapsed time beginning with theavailability of d
25、ictation or voice file for transcription andending when the transcribed document is delivered forauthentication. (E1959)3.1.14 verbatim transcription, ndocumentation that hasbeen transcribed exactly as dictated, without editing foraccuracy, consistency, completeness, or clarity. See The AAMTBook of
26、Style6for additional information.3.2 Acronyms:AAMT American Association for MedicalTranscriptionCMT Certified Medical TranscriptionistHIPAA Health Insurance Portability and Account-ability Act of 1996MT Medical Transcriptionist; Medical Tran-scriptionQA Quality AssuranceRFP Request(s) for Proposals4
27、. Significance and Use4.1 This guide lists the essential components of a qualityassurance program/quality improvement program for medicaltranscription and is applicable in all work environments. Itdescribes factors that should be considered when evaluating theindividuals and processes responsible fo
28、r producing patientcare documentation and for establishing procedures to addressand resolve problems that may arise in dictation and transcrip-tion. 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 d
29、evelop a quality assuranceprogram for individual medical transcriptionists, medical tran-scription departments within healthcare institutions, medicaltranscription businesses, and authors of dictation. A qualityassurance program verifies the consistency, correctness, andcompleteness of dictation and
30、 transcribed reports, including thesystematic identification and resolution of inaccuracies andinconsistencies, according to organizational standards. Merelyproofreading reports is not equivalent to a quality reviewprocess, which should involve comparison with the dictation atleast part of the time
31、and review for meaning of content all ofthe time.4.3 Quality is fundamental to the patient record, and clear,complete, accurate patient care documentation helps controlthe rising cost of health care and contributes to patient safety.The quality of the final report is the responsibility of both theau
32、thor and the medical transcriptionist. It is the result ofteamwork between the person dictating and the individualtranscribing. It should be noted that while production standardsare important, their value is diminished if quality is lacking.Likewise, transcribing dictation verbatim may not result in
33、quality documentation or clear communication. It is the tran-scriptionists responsibility to recognize, identify, and reportvoice files that lack accuracy, completeness, consistency, andclarity for corrective action.5. Dictation5.1 There are four areas that should be addressed with everynew author p
34、roviding dictation, and with all authors at regularintervals, particularly when changes occur in policies, staffing,or equipment, or a combination thereof. These four areas are(1) education and orientation, (2) document and patient iden-tification processes, (3) dictated content, and (4) confidentia
35、lityand security (See Guide E2344).5.2 Quality assurance of medical transcription begins withthe author of the dictation. The quality of transcribed docu-ments is dependent on the quality of dictation. Authors shouldbe educated and oriented in creating a timely, accurate, andunderstandable dictated
36、report, with emphasis on avoiding theuse or overuse of abbreviations, acronyms, back-formations,coined terms, jargon, profanity, short forms, and slang. 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
37、of authors should include anoverview of the report generation process, location and proper6Tessier, Claudia, The AAMT Book of Style for Medical Transcription, AmericanAssociation for Medical Transcription, 1995 (print), 1997 (CD-ROM).E2117 06 (2011)2use of equipment, report types and arrangement of
38、content,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
39、 for report 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. Thi
40、sincludes 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 necessaryequipment; and confirmation of patient identifiers by enteringnu
41、mbers correctly, providing pertinent dates, and accuratelyspelling patient names upon accessing the dictation system.Authors of healthcare documents should also correctly spellnew or unusual terminology and medications as necessary toensure accurate transcription. Authors should identify referringph
42、ysicians, consultants, and those receiving courtesy copies,providing spelling, complete addresses, or other informationthat will facilitate delivery.5.3.4 Priority of work types relative to dictation time andtranscription turnaround time should be included as part of theorientation process. Turnarou
43、nd time should be defined andexpectations clarified. See Guide E1959 for the definition ofturnaround time related to requests for proposals and out-sourced transcription.5.4 Document and Patient Identification Process:5.4.1 Instruction should be provided on the document iden-tification process, for
44、example, how to access the dictationsystem, how to indicate a priority dictation using the appropri-ate dictation prompts, how to separate multiple reports in onesession or call-in, and how to recognize technical problems andnotify designated personnel, indicating from what location thesystem is bei
45、ng 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, work type, and patientidentifiers promotes efficiency and enhances turnaround time.Dictation of several reports on multiple patients using only onepa
46、tient identifier limits the ability to track and locate specifiedpatient documentation. Entry of incorrect work types often willdelay transcription of stat or high-priority reports (See GuideE2344).5.5 Dictated Content:5.5.1 In order to document that the standard of patient careand all documentation
47、 requirements were met, authors shouldbe aware of risk management issues when dictating. Authorsshould adhere to standardized organizational requirements forrecommended or required report formats and order of contentsto facilitate communication among healthcare providers andenhance patient safety.5.
48、5.2 Content should be free from asides, profanity,derogatory, and other inappropriate comments. Such commentsmay be called to the attention of risk management personnel.5.5.3 Content should not include extensive use of abbrevia-tions that obstruct communication. Authors should be awarethat, when tra
49、nscribed, abbreviations, acronyms, short forms,jargon, coined terms, and back-formations may be expandedaccording to organizational policy or regulations. See JCAHODo Not Use Abbreviation List.5.5.4 Content should not include any specific references thatidentify the patient. See Guide E1902.5.6 Confidentiality and SecurityConfidentiality and secu-rity of author and patient information should be emphasized.See Guide E1902 regarding dictation and transcription confi-dentiality and security.6. Transcription6.1 It should be the medical transcriptionists responsibil
