ASTM_E_2117_-_06_2011.pdf

Designation:E211706(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 year 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-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,thusimproving 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 QApersonnel for medical transcription should havean understanding of the processes and variables or alternativesinvolved 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 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 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:2E1762 Guide for Electronic Authentication of Health CareInformationE1902 Specification for Management of the Confidentialityand Security of Dictation,Transcription,and TranscribedHealth Records(Withdrawn 2011)3E1959 Guide for Requests for Proposals Regarding MedicalTranscription Services for Healthcare InstitutionsE2344 Guide for Data Capture through the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-tions(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,forexample,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 electronically,and before 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,therapeuticprocedures,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 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,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.3The last approved version of this historical standard is referenced onwww.astm.org.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.*A Summary of Changes section appears at the end of this standardCopyright ASTM International,100 Barr Harbor Drive,PO Box C700,West Conshohocken,PA 19428-2959.United States1 3.1.6 originatorsee author.3.1.7 quality assurance audit,nexamination and reviewof transcribed documents to verify accuracy of work type,patient and