ASTM E2117-06(2011)
(Guide)Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription (Withdrawn 2020)
Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription (Withdrawn 2020)
SIGNIFICANCE AND USE
This guide lists the essential components of a quality assurance program/quality improvement program for medical transcription and is applicable in all work environments. It describes factors that should be considered when evaluating the individuals and processes responsible for producing patient care documentation and for establishing procedures to address and resolve problems that may arise in dictation and transcription. It clarifies who has the authority to make decisions regarding transcription style and editing and to resolve conflicts.
This guide may be used to develop a quality assurance program for individual medical transcriptionists, medical transcription departments within healthcare institutions, medical transcription businesses, and authors of dictation. A quality assurance program verifies the consistency, correctness, and completeness of dictation and transcribed reports, including the systematic identification and resolution of inaccuracies and inconsistencies, according to organizational standards. Merely proofreading reports is not equivalent to a quality review process, which should involve comparison with the dictation at least part of the time and review for meaning of content all of the time.
Quality is fundamental to the patient record, and clear, complete, accurate patient care documentation helps control the rising cost of health care and contributes to patient safety. The quality of the final report is the responsibility of both the author and the medical transcriptionist. It is the result of teamwork between the person dictating and the individual transcribing. It should be noted that while production standards are important, their value is diminished if quality is lacking. Likewise, transcribing dictation verbatim may not result in quality documentation or clear communication. It is the transcriptionist's responsibility to recognize, identify, and report voice files that lack accuracy, completeness, consistency, and clarity for cor...
SCOPE
1.1 This guide covers the establishment of a quality assurance program for dictation, medical transcription, and related processes. Quality assurance (QA) is necessary to ensure the accuracy of healthcare documentation. Quality documentation protects healthcare providers, facilitates reimbursement, and improves communication among healthcare providers, thus improving the overall quality of patient care. This guide establishes essential and desirable elements for quality healthcare documentation, but it is not purported to be an exhaustive list.
1.2 The QA personnel for medical transcription should have an understanding of the processes and variables or alternatives involved in the creation of medicolegal documents and an understanding of quality assurance issues as they pertain to medical transcription. Qualified personnel include certified medical transcriptionists (CMTs), quality assurance professionals, or individuals who hold other appropriately related credentials or degrees.
1.3 The medical transcriptionist (MT) and QA reviewer should establish a cooperative partnership so that the review outcomes are objective and educational to include corrective actions and remedies. Policies should be developed to minimize subjective review, which can lead to forceful implementation of one style at the expense of other reasonable choices. Objective review, including an appeals process, should follow organizational standards that have been agreed upon by the full team of QA personnel, MTs, and management staff.
WITHDRAWN RATIONALE
This guide covers the establishment of a quality assurance program for dictation, medical transcription, and related processes. Quality assurance (QA) is necessary to ensure the accuracy of healthcare documentation. Quality documentation protects healthcare providers, facilitates reimbursement, and improves communication among healthcare providers, thus improving the overall quality of patient...
General Information
Relations
Standards Content (Sample)
NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.
Contact ASTM International (www.astm.org) for the latest information
Designation:E2117 −06 (Reapproved 2011)
Standard Guide for
Identification and Establishment of a Quality Assurance
Program for Medical Transcription
This standard is issued under the fixed designation E2117; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (´) indicates an editorial change since the last revision or reapproval.
1. Scope* 2. Referenced Documents
2.1 ASTM Standards:
1.1 This guide covers the establishment of a quality assur-
E1762 Guide for Electronic Authentication of Health Care
ance program for dictation, medical transcription, and related
Information (Withdrawn 2017)
processes. Quality assurance (QA) is necessary to ensure the
E1902 Specification for Management of the Confidentiality
accuracy of healthcare documentation. Quality documentation
and Security of Dictation, Transcription, and Transcribed
protects healthcare providers, facilitates reimbursement, and
Health Records (Withdrawn 2011)
improves communication among healthcare providers, thus
E1959 Guide for Requests for Proposals Regarding Medical
improving the overall quality of patient care. This guide
Transcription Services for Healthcare Institutions
establishes essential and desirable elements for quality health-
E2344 GuideforDataCapturethroughtheDictationProcess
care documentation, but it is not purported to be an exhaustive
E2502 Guide for Medical Transcription Workstations
list.
2.2 Other Documents:
1.2 The QApersonnel for medical transcription should have
Public Law 104–191 Health Insurance Portability and Ac-
an understanding of the processes and variables or alternatives
countability Act of 1996 (HIPAA)
involved in the creation of medicolegal documents and an
Joint Commission on Accreditation of Healthcare Organiza-
understanding of quality assurance issues as they pertain to
tions (JCAHO) Do Not Use Abbreviation List
medical transcription. Qualified personnel include certified
medical transcriptionists (CMTs), quality assurance
3. Terminology
professionals, or individuals who hold other appropriately
3.1 Definitions:
related credentials or degrees.
3.1.1 author, n—the person(s) responsible and accountable
1.3 The medical transcriptionist (MT) and QA reviewer for the creation, content, accuracy, and completeness of each
should establish a cooperative partnership so that the review dictated and transcribed event or health record entry.
outcomes are objective and educational to include corrective
3.1.2 back-formation, n—a verb formed from a noun, for
actions and remedies. Policies should be developed to mini-
example, dialyze (verb) from dialysis (noun).
mize subjective review, which can lead to forceful implemen-
3.1.3 concurrent review, n—quality review of transcribed
tation of one style at the expense of other reasonable choices.
reports performed while listening to dictation and comparing
Objective review, including an appeals process, should follow
transcribed document content. Concurrent review is generally
organizational standards that have been agreed upon by the full
performed before reports are delivered to a patient’s record,
team of QA personnel, MTs, and management staff.
either in print form or electronically, and before they are made
1.4 This international standard was developed in accor-
available for author signature.
dance with internationally recognized principles on standard-
3.1.4 corrective action, n—a process used to rectify a
ization established in the Decision on Principles for the
situation or problem.
Development of International Standards, Guides and Recom-
mendations issued by the World Trade Organization Technical
For referenced ASTM standards, visit the ASTM website, www.astm.org, or
Barriers to Trade (TBT) Committee.
contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM
Standards volume information, refer to the standard’s Document Summary page on
the ASTM website.
The last approved version of this historical standard is referenced on
This guide is under the jurisdiction of ASTM Committee E31 on Healthcare www.astm.org.
Informatics and is the direct responsibility of Subcommittee E31.15 on Healthcare Available from U.S. Government Printing Office, Superintendent of
Information Capture and Documentation. Dcouments, 732 N. Capitol St., N.W., Mail Stop: SDE, Washington, D.C. 20401.
Current edition approved July 1, 2011. Published August 2011. Originally See also http://aspe.hhs.gov/adminsimp.
approved in 2000. Last previous edition approved in 2006 as E2117 – 06. DOI: Joint Commission on Accreditation of Healthcare Organizations: www.jca-
10.1520/E2117-06R11. ho.org.
*A Summary of Changes section appears at the end of this standard
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
E2117−06 (2011)
3.1.5 medical transcription, n—the process of interpreting 4. Significance and Use
and transcribing dictation by physicians and other healthcare
4.1 This guide lists the essential components of a quality
providers regarding patient assessment, workup, therapeutic
assurance program/quality improvement program for medical
procedures, clinical course, diagnosis, prognosis, etc., into
transcription and is applicable in all work environments. It
readable text, whether on paper or on computer, in order to
describesfactorsthatshouldbeconsideredwhenevaluatingthe
document patient care and facilitate delivery of healthcare
individuals and processes responsible for producing patient
services. (AAMT Book of Style; E1959)
care documentation and for establishing procedures to address
3.1.6 originator—see author .
and resolve problems that may arise in dictation and transcrip-
tion. It clarifies who has the authority to make decisions
3.1.7 quality assurance audit, n—examination and review
regarding transcription style and editing and to resolve con-
of transcribed documents to verify accuracy of work type,
flicts.
patient and author identification, and that dictated content was
appropriately transcribed and edited, with findings communi-
4.2 This guide may be used to develop a quality assurance
cated to and reviewed with appropriate staff. A quality assur-
program for individual medical transcriptionists, medical tran-
ance audit is generally performed after reports are delivered to
scription departments within healthcare institutions, medical
a patient’s record and may also be called a retrospective
transcription businesses, and authors of dictation. A quality
review.
assurance program verifies the consistency, correctness, and
completenessofdictationandtranscribedreports,includingthe
3.1.8 quality assurance for medical transcription, n—the
systematic identification and resolution of inaccuracies and
process of review that is intended to provide adequate confi-
inconsistencies, according to organizational standards. Merely
dence that dictated patient care documentation is transcribed in
proofreading reports is not equivalent to a quality review
a clear, consistent, accurate, complete, and timely manner and
process, which should involve comparison with the dictation at
that it satisfies stated or implied requirements for dictated and
least part of the time and review for meaning of content all of
transcribed documentation of patient care. A quality assurance
the time.
program may also be called a quality improvement program.
3.1.9 remedies, n—alternatives for correcting a situation or 4.3 Quality is fundamental to the patient record, and clear,
problem at the MT or author level. complete, accurate patient care documentation helps control
the rising cost of health care and contributes to patient safety.
3.1.10 retrospective audit, n—quality review of transcribed
The quality of the final report is the responsibility of both the
reports performed after documents have been released for
author and the medical transcriptionist. It is the result of
author signature and delivered to a patient’s record. The voice
teamwork between the person dictating and the individual
file may no longer be available for comparison with the
transcribing. It should be noted that while production standards
transcribed documents. It is preferable that retrospective audit
are important, their value is diminished if quality is lacking.
be carried out with voice file.
Likewise, transcribing dictation verbatim may not result in
3.1.11 stat, adj—ofhighpriority,orurgent,suchasdictation
quality documentation or clear communication. It is the tran-
requiring immediate transcription and delivery.
scriptionist’s responsibility to recognize, identify, and report
3.1.12 text expander, n—computer software that allows a
voice files that lack accuracy, completeness, consistency, and
few letters or symbols to be expanded to a phrase or sentence
clarity for corrective action.
in order to enhance productivity.
5. Dictation
3.1.13 turnaround time, n—elapsed time beginning with the
availability of dictation or voice file for transcription and
5.1 There are four areas that should be addressed with every
ending when the transcribed document is delivered for
new author providing dictation, and with all authors at regular
authentication. (E1959) intervals, particularly when changes occur in policies, staffing,
or equipment, or a combination thereof. These four areas are
3.1.14 verbatim transcription, n—documentation that has
(1) education and orientation, (2) document and patient iden-
been transcribed exactly as dictated, without editing for
tification processes, (3) dictated content, and (4) confidentiality
accuracy, consistency, completeness, or clarity. See The AAMT
and security (See Guide E2344).
Book of Style for additional information.
5.2 Quality assurance of medical transcription begins with
3.2 Acronyms:
the author of the dictation. The quality of transcribed docu-
AAMT American Association for Medical
ments is dependent on the quality of dictation. Authors should
Transcription
CMT Certified Medical Transcriptionist
be educated and oriented in creating a timely, accurate, and
HIPAA Health Insurance Portability and Account-
understandable dictated report, with emphasis on avoiding the
ability Act of 1996
use or overuse of abbreviations, acronyms, back-formations,
MT Medical Transcriptionist; Medical Tran-
scription
coined terms, jargon, profanity, short forms, and slang. Accu-
QA Quality Assurance
racy and completeness of document content are the responsi-
RFP Request(s) for Proposals
bility of the author.
5.3 Education and Orientation:
5.3.1 Educationandorientationofauthorsshouldincludean
Tessier, Claudia, The AAMT Book of Style for Medical Transcription,American
Association for Medical Transcription, 1995 (print), 1997 (CD-ROM). overview of the report generation process, location and proper
E2117−06 (2011)
use of equipment, report types and arrangement of content, 5.5.3 Content should not include extensive use of abbrevia-
proper identification of the patient, and turnaround time re- tions that obstruct communication. Authors should be aware
quirements. Potential problems and procedures for their reso- that, when transcribed, abbreviations, acronyms, short forms,
lution should also be addressed. jargon, coined terms, and back-formations may be expanded
5.3.2 To ensure accuracy, completeness, and consistency of according to organizational policy or regulations. See JCAHO
documentation, regulatory requirements and organizational Do Not Use Abbreviation List.
policies and guidelines for report formats and organization of
5.5.4 Contentshouldnotincludeanyspecificreferencesthat
content should be followed. identify the patient. See Guide E1902.
5.3.3 A mechanism for feedback should be provided to the
5.6 Confidentiality and Security—Confidentiality and secu-
author regarding the dictation or the process to ensure that the
rity of author and patient information should be emphasized.
author is aware of any problems that may preclude clear,
See Guide E1902 regarding dictation and transcription confi-
accurate documentation or impede timely transcription. This
dentiality and security.
includes the choice of a quiet and secure area in which to
dictate; adequate preparation before beginning the dictation
6. Transcription
process; self-identification by spelling name and providing
6.1 It should be the medical transcriptionist’s responsibility
identification number; proficiency in the use of necessary
to prepare patient care documents that are as accurate,
equipment; and confirmation of patient identifiers by entering
complete, and timely as possible.
numbers correctly, providing pertinent dates, and accurately
spelling patient names upon accessing the dictation system.
6.2 Education and Orientation:
Authors of healthcare documents should also correctly spell
6.2.1 Medical transcriptionists should strive to expand skills
new or unusual terminology and medications as necessary to
andknowledgebyregularparticipationincontinuingeducation
ensure accurate transcription.Authors should identify referring
and professional development activities. Relevant topics may
physicians, consultants, and those receiving courtesy copies,
include clinical diagnosis and treatment, medical and profes-
providing spelling, complete addresses, or other information
sional ethics, technology, professional practice and
that will facilitate delivery.
development, ergonomics, and industry trends.
5.3.4 Priority of work types relative to dictation time and
6.2.2 MTs should participate in the development of a QA
transcription turnaround time should be included as part of the
program and be responsible for assisting others in assuring
orientation process. Turnaround time should be defined and
quality documentation.
expectations clarified. See Guide E1959 for the definition of
6.2.3 MTs should strive to prevent injuries by using sound
turnaround time related to requests for proposals and out-
ergonomic techniques, thus facilitating the timely and accurate
sourced transcription.
production of transcribed documents (See Guide E2502).
5.4 Document and Patient Identification Process:
6.2.4 Dictation should be accessed and evaluated by the
5.4.1 Instruction should be provided on the document iden-
medical transcriptionist to determine the extent to which it can
tification process, for example, how to access the dictation
be transcribed. If problems arise related to technical
system, how to indicate a priority dictation using the appropri-
difficulties, author technique, or the individual MT’s skill and
ate dictation prompts, how to separate multiple reports in one
experience, appropriate o
...
Questions, Comments and Discussion
Ask us and Technical Secretary will try to provide an answer. You can facilitate discussion about the standard in here.