1、Designation: E2117 06 (Reapproved 2011)An American National StandardStandard 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 yea
2、r oforiginal adoption or, in 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
3、-ance program for 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, thusim
4、proving the overall 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 alte
5、rnativesinvolved 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 rela
6、tedcredentials 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
7、 forceful implemen-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:2E17
8、62 Guide for Electronic Authentication of Health CareInformationE1902 Specification for Management of the Confidentialityand Security of Dictation, Transcription, and TranscribedHealth Records3E1959 Guide for Requests for Proposals Regarding MedicalTranscription Services for Healthcare InstitutionsE
9、2344 Guide for Data Capture through the Dictation Pro-cessE2502 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-tions (JCAHO) Do Not Use Abb
10、reviation 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, forexample, dialyze (verb) from di
11、alysis (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 electronically, and before
12、they are 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, therapeuticproce
13、dures, clinical 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; E1959)1This guide is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and
14、is the direct responsibility of Subcommittee E31.15 on HealthcareInformation 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,
15、 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 onthe ASTM website.3Withdrawn. The last approved version of this historical standard is referencedon www.astm.o
16、rg.4Available 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.5Joint Commission on Accreditation of Healthcare Organizations: www.jca-ho.org.1*A Summary of Changes section appea
17、rs at the end of this standard.Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.3.1.6 originatorsee author.3.1.7 quality assurance audit, nexamination and reviewof transcribed documents to verify accuracy of work type,patient and autho
18、r 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 called a retrospectivereview.3.1.
19、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 implied requirements for dictated
20、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 transcribedreports performed after doc
21、uments 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 priority, or urgent, such as dicta-
22、tion requiring 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 dictation or voice file for
23、transcription andending when the transcribed document is delivered for authen-tication. (E1959)3.1.14 verbatim transcription, ndocumentation that hasbeen transcribed exactly as dictated, without editing for accu-racy, consistency, completeness, or clarity. See The AAMTBook of Style6for additional in
24、formation.3.2 Acronyms:AAMT American Association for Medical TranscriptionCMT Certified Medical TranscriptionistHIPAA Health Insurance Portability and AccountabilityAct of 1996MT Medical Transcriptionist; Medical TranscriptionQA Quality AssuranceRFP Request(s) for Proposals4. Significance and Use4.1
25、 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 for producing patientcare d
26、ocumentation 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 develop a quality assuranc
27、eprogram 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 transcribed reports, inc
28、luding 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 and review for meaning of
29、 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 theauthor and the medical tran
30、scriptionist. 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 inquality documentation or
31、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 providing dictation, and w
32、ith 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) confidentialityand security (See Gui
33、de 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 report, with emphasis on
34、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 of authors should include
35、 anoverview of the report generation process, location and properuse of equipment, report types and arrangement of 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 accurac
36、y, completeness, and consistency ofdocumentation, regulatory requirements and organizationalpolicies and guidelines 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 th
37、eauthor is aware of any problems that may preclude clear,accurate documentation or impede timely transcription. Thisincludes the choice of a quiet and secure area in which to6Tessier, Claudia, The AAMT Book of Style for Medical Transcription, AmericanAssociation for Medical Transcription, 1995 (prin
38、t), 1997 (CD-ROM).E2117 06 (2011)2dictate; 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 enteringnumbers correctly, providin
39、g 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 referringphysicians, consultants, an
40、d 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. Turnaround time should be defined
41、 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 example, how to access th
42、e 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 being accessed and the natur
43、e 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 onepatient identifier limits t
44、he 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 requirements were met, a
45、uthors 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.5.5.2 Content should be fre
46、e from asides, profanity, deroga-tory, and other inappropriate comments. Such comments maybe 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 transcribed, abbreviations
47、, 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 Securit
48、yConfidentiality 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 responsibilityto prepare patient care documents that are as accurat
49、e, com-plete, and timely as possible.6.2 Education and Orientation:6.2.1 Medical transcriptionists should strive to expand skillsand 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 str
