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(Guide)Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription (Withdrawn 2020)
Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription (Withdrawn 2020)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
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
1
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
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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
3
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
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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
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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
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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
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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.
3
The last approved version of this historical standard is referenced on
1
This guide is under the jurisdiction of ASTM Committee E31 on Healthcare www.astm.org.
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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.
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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
...
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