1、Designation: E 2344 04An American National StandardStandard Guide forData Capture through the Dictation Process1This standard is issued under the fixed designation E 2344; the number immediately following the designation indicates the year oforiginal adoption or, in the case of revision, the year of
2、 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. Scope1.1 This guide identifies ways to improve the quality ofhealthcare documentation through the dictation process. Thisguid
3、e will assist dictating authors (physicians, physician assis-tants, nurses, therapists, and other healthcare professionals) infacilitating their use of dictation in the healthcare environment,that is, hospital, clinic, physician practice, or multi-campushealthcare system.1.2 This guide will aid in t
4、he continuity of patient care,privacy and confidentiality issues, risk management issues,optimal coding for reimbursement, compliance with legislativeand regulatory requirements, and turnaround time.1.3 The complexity of the language of medicine, the dy-namics of the healthcare environment, and the
5、sophistication ofthe dictation systems present a formidable challenge fordictating authors. This guide will facilitate a quality dictationmessage.1.4 This guide does not address the medical transcriptionprocess.1.5 This standard does not purport to address all of thesafety concerns, if any, associat
6、ed with its use. It is theresponsibility of the user of this standard to establish appro-priate safety and health practices and determine the applica-bility of regulatory requirements prior to use.2. Referenced Documents2.1 ASTM Standards:2E 1902 Specification for Management of the Confidentialityan
7、d Security of Dictation, Transcription, and TranscribedHealth RecordsE2117 Guide for Identification and Establishment of Qual-ity Assurance for Medical TranscriptionE 2184 Specification for Healthcare Document Formats3. Terminology3.1 Definitions:3.1.1 analog, nof, relating to, or being a mechanism
8、inwhich data is represented by continuously variable physicalquantities, that is, recording tape.3.1.2 blanks, nmissing text that must be filled in asdirected by the dictating author.3.1.3 confidential, adjstatus accorded to data or informa-tion indicating that it is sensitive, and therefore, it mus
9、t beprotected against theft, disclosure, or improper use.3.1.4 dictate workstation (or dictate station), nlocationwith a device for input of voice dictation.3.1.5 dictating author, none who dictates information tobe transcribed, that is, healthcare students and healthcareprofessionals.3.1.6 dictatio
10、n message (or digital voice file), nunit ofinformation that consists of both audio (voice) and its dataelements.3.1.7 document, nreport in any form (print, electronic, orvoice file).3.1.8 healthcare environment, nany facility whose pri-mary purpose is delivery of healthcare, that is, hospital, clini
11、c,physician practice, or multi-campus healthcare system.3.1.9 medical transcription, nprocess of interpreting andtranscribing dictation by physicians and other healthcare pro-fessionals regarding patient assessment, workup, therapeuticprocedures, clinical course, diagnosis, prognosis, and so forthin
12、to readable text to document patient care and facilitatedelivery of healthcare services.3.1.10 microphone, ninstrument whereby sound wavesare caused to generate or modulate an electric current usuallyfor the purpose of transmitting or recording sound (as speech ormusic).3.1.11 microphone element, nd
13、iaphragm of the sound-collecting source of a microphone.3.1.12 quality assurance, nprocess of review of a health-care document that will provide adequate confidence thatdictated patient care documentation is transcribed in a clear,consistent, accurate, and complete manner.3.1.13 quality editor, nper
14、son who performs quality as-surance reviews and/or corrections.1This guide is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.15 on HealthInformation Capture and Documentation.Current edition approved Jan. 1, 2004. Published
15、March 2004.2For 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 onthe ASTM website.1Copyright ASTM International, 100 Barr Harbor Dri
16、ve, PO Box C700, West Conshohocken, PA 19428-2959, United States.3.1.14 risk management, nhealthcare environment activi-ties that identify, evaluate, reduce, and prevent the risk ofinjury and loss to patients, visitors, staff, and the healthcareenvironment itself.3.1.15 speech recognition, ncomputer
17、ized translation ofspeech to text.3.1.16 stat, adjhigh priority, or urgent, such as dictationrequiring immediate transcription.3.1.17 telephony, nthe use or operation of an apparatusfor transmission of sounds between widely removed pointswith or without connecting wires.3.1.18 template, npattern or
18、guide.3.1.19 text, nmain body of printed or written matter.3.1.20 transcribe, vsee medical transcription.3.1.21 turnaround time (TAT), nelapsed time beginningwith availability of the voice for transcription and ending whenthe transcribed document is available for authentication (seeGuide E2117).3.1.
19、22 unique identifier, na number used by only one (1)person that identifies that user.3.1.23 voice activation, ntechnology that allows record-ing to begin when dictation message begins.3.1.24 voice file, ndigitalized audio portion of a dictationmessage.3.2 Acronyms, Abbreviations, and Short Forms:3.2
20、.1 AAMTAmerican Association for Medical Transcrip-tion3.2.2 HIPAAHealth Insurance Portability and Account-ability Act of 199633.2.3 MR#medical record number3.2.4 MTmedical transcriptionist3.2.5 QAquality assurance3.2.6 TATturnaround time4. Significance and Use4.1 This document provides guidelines fo
21、r dictation tech-niques and environments that contribute to quality documen-tation, that is:4.1.1 Educational facilities for the purpose of introducingand training of dictation techniques, and4.1.2 Healthcare professionals for preferred dictation tech-niques.4.2 This document provides recommendation
22、s to help createquality documentation for the following reasons:4.2.1 Correct Coding for Reimbursement4.2.1.1 Reports that require no QA intervention increaseefficiency of the reimbursement process and reduce discrepan-cies for the healthcare environment and healthcare provider.4.2.2 Risk Management
23、, Legal, and Peer Review4.2.2.1 Reports that require no QA intervention reduce legalexposure for the healthcare environment and the healthcareprovider.4.2.3 Improved TAT4.2.3.1 Reports that require no QA intervention reduceturnaround time, are more cost-effective, and possibly reducedelay in patient
24、 care.4.2.4 Legislative and Regulatory Compliance4.2.4.1 Dictation performed in preferred environmentswould not compromise patient confidentiality and the patientsright to privacy and would be compliant with legislative andregulatory requirements.4.2.5 Continuity of Patient Care4.2.5.1 Documents wit
25、h missing text (blanks) compromisequality. These should be filled in or corrected as directed by thedictating author upon authentication of the report.4.2.6 Improved Communication Between Healthcare Pro-fessionals4.2.6.1 Timely quality documentation can enhance commu-nication within the dynamic heal
26、thcare setting. Patient safetymay also be improved when transcribed documents are used toreplace handwritten documentation by healthcare profession-als.4.3 This document does not address security issues. Refer toSpecification E 1902.5. Dictation and Orientation Principles5.1 Quality documentation be
27、gins with quality dictation.The quality of transcribed documents is dependent in part onthe quality of the dictation message.5.2 Formal orientation within healthcare environments fordictating authors makes the process easier and improves thequality of the dictation message (see Guide E2117).5.2.1 Al
28、l dictating authors should receive training on thedictation processes and the overall documentation within theirhealthcare environments initially and when changes occur inpolicies or equipment.5.2.1.1 Address any regulatory requirements and institu-tional policies and guidelines for report formats a
29、nd organiza-tion of content.5.2.1.2 Provide guidelines for report turnaround times andthe appropriate use of a stat designation for prioritizing reports.5.2.1.3 Use only facility-approved abbreviations within thedictating message and avoid the use of other abbreviations,jargon, slang, acronyms, and/
30、or coined terms.5.2.1.4 Maintain a quiet and secure area for the dictationprocess (see Specification E 1902). Advise dictating authors touse the designated dictation areas to avoid background noises,distractions, interruptions and confidentiality issues. Advisedictating authors to avoid eating, gum
31、chewing, yawning,smoking, etc., while dictating. Advise dictating authors toavoid side conversations and background distractions such asvoices, telephone ringing, and/or music that may obscure thedictation.5.2.1.5 Advise dictating authors to avoid profanity and/orderogatory, and other inappropriate
32、comments while dictating.5.2.1.6 Include the feedback system about the dictationprocess regarding any mechanical, technical, or other problemsthat may interfere with a clear, complete, and accurate docu-ment (see Guide E2117).5.2.1.7 Explain policies and procedures for dictating anamended report.3Av
33、ailable from U.S. Government Printing Office Superintendent of Documents,732 N. Capitol St., NW, Mail Stop: SDE, Washington, DC 20401.E23440425.3 Use conversational speed and volume for optimal dic-tation message.5.4 Instruct dictating authors on the functions of the dicta-tion system used within th
34、eir healthcare environment. Theseinclude, but are not limited to, the following:5.4.1 Use of the pause mechanism, use of the review mode,use of the insertion mode.5.4.2 Use of the types of phones used for dictating. Refrainfrom using speaker phones, portable phones, cell phones,public phones, and ot
35、her recording devices when withinhearing distance of others (see Specification E 1902).5.4.3 Use of microphone settings to avoid clipped wordsand phrases, proper distance of microphone and microphoneelement from mouth.5.4.4 Use of assigned unique identifier for each dictator toassure appropriate acc
36、ess to dictation system.5.4.5 Use of appropriate work type identifier for appropriatepriority of reports. Use of a stat identifier specifically for statdictation.5.4.6 Proper separation and patient identification of indi-vidual reports dictated within one session.5.4.6.1 One separate dictation for e
37、ach completed documentseparating different patients as well as the same patient with adifferent procedure or report type (See Note 1).NOTE 1This reduces misfiled information, which may result inre-dictation.5.5 Report Types and Format of Contents5.5.1 Use standardized headings or templates or both (
38、referto Specification E 2184).5.5.2 For optimal memory recall, perform dictation in atimely manner from the patient encounter.5.5.3 Have all pertinent information available during timeof dictation.5.5.4 Provide any special instructions at the beginning ofdictation.5.5.5 At the beginning of each dict
39、ation, state dictatingauthor name and number, patient name or number or both,type/title of report, appropriate dates, and any other informa-tion pertinent to the healthcare record as required by environ-ment.5.5.6 Provide complete names, addresses, and courtesycopy information.5.5.7 Provide correct
40、spelling for new or unusual terminol-ogy and all names.5.6 Confidentiality and Security5.6.1 Dictate only in an environment that will maintainpatient confidentiality and security of healthcare information incompliance with legislative and regulatory requirements (seeSpecification E 1902).5.6.2 Avoid
41、 the use of any patient-identifying informationwithin the text of the report (see Specification E 1902).5.7 Unique Identifiers5.7.1 Each individual authorized to dictate shall use uniqueidentifiers to assure appropriate dictation system access (seeSpecification E 1902).5.7.2 Document procedures to d
42、isable access for persons nolonger authorized to use the dictation system.5.7.3 An identifier serves as a permanent record and shouldnot be reassigned to another individual.6. Mechanisms to Capture Dictation6.1 Dictating authors may use one or more of severaldifferent methods and should be familiar
43、with the equipmentthey use including handling, storage, and security.6.1.1 Analog6.1.1.1 Store in protective case with appropriate labeling.6.1.1.2 Erase tapes before using again.6.1.1.3 Replace tapes every three months to avoid breakageand reduced recording quality.6.1.1.4 Safeguard tapes with dict
44、ation to assure confidenti-ality and privacy of patient information (see SpecificationE 1902).6.1.1.5 Refrain from using the voice-activated equipment.6.1.1.6 Use the correct tape speed (4.8 for standard sizerecorders, 2.4 for microcassettes).6.1.1.7 Store tapes in a secure environment to ensureunau
45、thorized access is avoided.6.1.1.8 Refrain from the use of conference mode for sensi-tivity issues.6.1.1.9 Always begin dictation at the beginning of side Aand indicate if side B is used.6.1.1.10 Indicate end of dictation.6.1.1.11 Tapes greater in length than 60 min (30 min eachside) compromise TAT
46、and quality.6.1.1.12 Keep tapes away from extreme temperatures, mag-nets, abusive handling, etc.6.1.1.13 Deliver tapes with dictation in a timely and securemanner.6.1.2 Digital6.1.2.1 Telephony-based Systems(1) Correctly key in appropriate numbers, which areessential for retrieval, TAT, editing, rev
47、iew, etc.(2) Be aware of connection quality and refrain from usingstatic lines for optimal sound quality.(3) Cell phones and portable phones should be avoidedwhen within hearing distance of others (see SpecificationE 1902).(4) Indicate end of dictation.(5) Complete dictation in timely and secure man
48、ner.6.1.2.2 Hand-held Digital Systems(1) Correctly key in appropriate numbers, which areessential for retrieval, TAT, editing, review, etc.(2) Safeguard units with dictation to assure confidentialityand privacy of patient information.(3) Refrain from using the voice-activated devices.(4) Indicate en
49、d of dictation.(5) Transfer voice files in a timely and secure manner.6.1.3 Speech Recognition Systems6.1.3.1 Correctly key in appropriate numbers, which areessential for retrieval, TAT, editing, review, etc.6.1.3.2 Be aware of microphone placement and connectionquality for optimal sound quality. Use noise-canceling micro-phones.6.1.3.3 Recording devices should be avoided when withinhearing distance of others (see Specification E 1902).6.1.3.4 Refrain from using the voice-activated devices.E23440436.1.3.5 Indicate end of dictation.6.1.3.6 Transfer or com
