ASTM_E_2344_-_04_2011.pdf

Designation:E234404(Reapproved 2011)An American National StandardStandard Guide forData Capture through the Dictation Process1This standard is issued under the fixed designation E2344;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.Scope1.1 This guide identifies ways to improve the quality ofhealthcare documentation through the dictation process.Thisguide 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 the 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 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,associated 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:2E1902 Specification for Management of the Confidentialityand Security of Dictation,Transcription,and TranscribedHealth Records(Withdrawn 2011)3E2117 Guide for Identification and Establishment of a Qual-ity Assurance Program for Medical TranscriptionE2184 Specification for Healthcare Document Formats(Withdrawn 2011)33.Terminology3.1 Definitions:3.1.1 analog,nof,relating to,or being a mechanism inwhich data is represented by continuously variable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 must 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 dictation 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,clinic,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 forthinto 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,ndiaphragm 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 that1This 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 July 2011.Originally published2004.Last previous edition approved 2004 as E234404.DOI:10.1520/E2344-04R11.2For 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.Copyright ASTM International,100 Barr Harbor Drive,PO Box C700,West Conshohocken,PA 19428-2959.United States1 dictated patient care documentation is transcribed in a clear,consistent,accurate,and complete manner.3.1.13 quality editor,nperson who performs quality assur-ance reviews and/or corrections.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,ncomputerized translation ofspeech to text.3.1.16 stat,adjhigh prio