ASTM E2344-04
(Guide)Standard Guide for Data Capture through the Dictation Process
Standard Guide for Data Capture through the Dictation Process
SCOPE
1.1 This guide identifies ways to improve the quality of healthcare documentation through the dictation process. This guide will assist dictating authors (physicians, physician assistants, nurses, therapists, and other healthcare professionals) in facilitating their use of dictation in the healthcare environment, that is, hospital, clinic, physician practice, or multi-campus healthcare 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 legislative and regulatory requirements, and turnaround time.
1.3 The complexity of the language of medicine, the dynamics of the healthcare environment, and the sophistication of the dictation systems present a formidable challenge for dictating authors. This guide will facilitate a quality dictation message.
1.4 This guide does not address the medical transcription process.
1.5 This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory requirements prior to use.
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An American National Standard
Designation:E2344–04
Standard Guide for
Data Capture through the Dictation Process
This standard is issued under the fixed designation E2344; 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 E2184 Specification for Healthcare Document Formats
1.1 This guide identifies ways to improve the quality of
3. Terminology
healthcare documentation through the dictation process. This
3.1 Definitions:
guide will assist dictating authors (physicians, physician assis-
3.1.1 analog, n—of, relating to, or being a mechanism in
tants, nurses, therapists, and other healthcare professionals) in
which data is represented by continuously variable physical
facilitating their use of dictation in the healthcare environment,
quantities, that is, recording tape.
that is, hospital, clinic, physician practice, or multi-campus
3.1.2 blanks, n—missing text that must be filled in as
healthcare system.
directed by the dictating author.
1.2 This guide will aid in the continuity of patient care,
3.1.3 confidential, adj—status accorded to data or informa-
privacy and confidentiality issues, risk management issues,
tion indicating that it is sensitive, and therefore, it must be
optimal coding for reimbursement, compliance with legislative
protected against theft, disclosure, or improper use.
and regulatory requirements, and turnaround time.
3.1.4 dictate workstation (or dictate station), n—location
1.3 The complexity of the language of medicine, the dy-
with a device for input of voice dictation.
namicsofthehealthcareenvironment,andthesophisticationof
3.1.5 dictating author, n—one who dictates information to
the dictation systems present a formidable challenge for
be transcribed, that is, healthcare students and healthcare
dictating authors. This guide will facilitate a quality dictation
professionals.
message.
3.1.6 dictation message (or digital voice file), n—unit of
1.4 This guide does not address the medical transcription
information that consists of both audio (voice) and its data
process.
elements.
1.5 This standard does not purport to address all of the
3.1.7 document, n—report in any form (print, electronic, or
safety concerns, if any, associated with its use. It is the
voice file).
responsibility of the user of this standard to establish appro-
3.1.8 healthcare environment, n—any facility whose pri-
priate safety and health practices and determine the applica-
mary purpose is delivery of healthcare, that is, hospital, clinic,
bility of regulatory requirements prior to use.
physician practice, or multi-campus healthcare system.
2. Referenced Documents 3.1.9 medical transcription, n—process of interpreting and
transcribing dictation by physicians and other healthcare pro-
2.1 ASTM Standards:
fessionals regarding patient assessment, workup, therapeutic
E1902 Specification for Management of the Confidentiality
procedures, clinical course, diagnosis, prognosis, and so forth
and Security of Dictation, Transcription, and Transcribed
into readable text to document patient care and facilitate
Health Records
delivery of healthcare services.
E2117 Guide for Identification and Establishment of a
3.1.10 microphone, n—instrument whereby sound waves
Quality Assurance Program for Medical Transcription
are caused to generate or modulate an electric current usually
forthepurposeoftransmittingorrecordingsound(asspeechor
This guide is under the jurisdiction of ASTM Committee E31 on Healthcare
music).
Informatics and is the direct responsibility of Subcommittee E31.15 on Health
3.1.11 microphone element, n—diaphragm of the sound-
Information Capture and Documentation.
collecting source of a microphone.
Current edition approved Jan. 1, 2004. Published March 2004. DOI: 10.1520/
E2344-04.
3.1.12 quality assurance, n—process of review of a health-
For referenced ASTM standards, visit the ASTM website, www.astm.org, or
care document that will provide adequate confidence that
contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM
dictated patient care documentation is transcribed in a clear,
Standards volume information, refer to the standard’s Document Summary page on
the ASTM website. consistent, accurate, and complete manner.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
E2344–04
3.1.13 quality editor, n—person who performs quality as- 4.2.3.1 Reports that require no QA intervention reduce
surance reviews and/or corrections. turnaround time, are more cost-effective, and possibly reduce
3.1.14 risk management, n—healthcare environment activi- delay in patient care.
ties that identify, evaluate, reduce, and prevent the risk of 4.2.4 Legislative and Regulatory Compliance
injury and loss to patients, visitors, staff, and the healthcare
4.2.4.1 Dictation performed in preferred environments
environment itself. would not compromise patient confidentiality and the patient’s
3.1.15 speech recognition, n—computerized translation of
right to privacy and would be compliant with legislative and
speech to text. regulatory requirements.
3.1.16 stat, adj—high priority, or urgent, such as dictation
4.2.5 Continuity of Patient Care
requiring immediate transcription.
4.2.5.1 Documents with missing text (blanks) compromise
3.1.17 telephony, n—the use or operation of an apparatus
quality.These should be filled in or corrected as directed by the
for transmission of sounds between widely removed points
dictating author upon authentication of the report.
with or without connecting wires.
4.2.6 Improved Communication Between Healthcare Pro-
3.1.18 template, n—pattern or guide.
fessionals
3.1.19 text, n—main body of printed or written matter.
4.2.6.1 Timely quality documentation can enhance commu-
3.1.20 transcribe, v—see medical transcription.
nication within the dynamic healthcare setting. Patient safety
3.1.21 turnaround time (TAT), n—elapsed time beginning
may also be improved when transcribed documents are used to
with availability of the voice for transcription and ending when
replace handwritten documentation by healthcare profession-
the transcribed document is available for authentication (see
als.
Guide E2117).
4.3 Thisdocumentdoesnotaddresssecurityissues.Referto
3.1.22 unique identifier, n—a number used by only one (1)
Specification E1902.
person that identifies that user.
3.1.23 voice activation, n—technology that allows record-
5. Dictation and Orientation Principles
ing to begin when dictation message begins.
5.1 Quality documentation begins with quality dictation.
3.1.24 voice file, n—digitalized audio portion of a dictation
The quality of transcribed documents is dependent in part on
message.
the quality of the dictation message.
3.2 Acronyms, Abbreviations, and Short Forms:
5.2 Formal orientation within healthcare environments for
3.2.1 AAMT—AmericanAssociation for MedicalTranscrip-
dictating authors makes the process easier and improves the
tion
quality of the dictation message (see Guide E2117).
3.2.2 HIPAA—Health Insurance Portability and Account-
5.2.1 All dictating authors should receive training on the
ability Act of 1996
dictation processes and the overall documentation within their
3.2.3 MR#—medical record number
healthcare environments initially and when changes occur in
3.2.4 MT—medical transcriptionist
policies or equipment.
3.2.5 QA—quality assurance
5.2.1.1 Address any regulatory requirements and institu-
3.2.6 TAT—turnaround time
tional policies and guidelines for report formats and organiza-
tion of content.
4. Significance and Use
5.2.1.2 Provide guidelines for report turnaround times and
4.1 This document provides guidelines for dictation tech-
the appropriate use of a stat designation for prioritizing reports.
niques and environments that contribute to quality documen-
5.2.1.3 Use only facility-approved abbreviations within the
tation, that is:
dictating message and avoid the use of other abbreviations,
4.1.1 Educational facilities for the purpose of introducing
jargon, slang, acronyms, and/or coined terms.
and training of dictation techniques, and
5.2.1.4 Maintain a quiet and secure area for the dictation
4.1.2 Healthc
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