ASTM E2344-04(2011)
(Guide)Standard Guide for Data Capture through the Dictation Process (Withdrawn 2020)
Standard Guide for Data Capture through the Dictation Process (Withdrawn 2020)
SIGNIFICANCE AND USE
This document provides guidelines for dictation techniques and environments that contribute to quality documentation, that is:
Educational facilities for the purpose of introducing and training of dictation techniques, and
Healthcare professionals for preferred dictation techniques.
This document provides recommendations to help create quality documentation for the following reasons:
Correct Coding for Reimbursement
Reports that require no QA intervention increase efficiency of the reimbursement process and reduce discrepancies for the healthcare environment and healthcare provider.
Risk Management, Legal, and Peer Review
Reports that require no QA intervention reduce legal exposure for the healthcare environment and the healthcare provider.
Improved TAT
Reports that require no QA intervention reduce turnaround time, are more cost-effective, and possibly reduce delay in patient care.
Legislative and Regulatory Compliance
Dictation performed in preferred environments would not compromise patient confidentiality and the patient's right to privacy and would be compliant with legislative and regulatory requirements.
Continuity of Patient Care
Documents with missing text (blanks) compromise quality. These should be filled in or corrected as directed by the dictating author upon authentication of the report.
Improved Communication Between Healthcare Professionals
Timely quality documentation can enhance communication within the dynamic healthcare setting. Patient safety may also be improved when transcribed documents are used to replace handwritten documentation by healthcare professionals.
This document does not address security issues. Refer to Specification E1902.
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.
WITHDRAWN RATIONALE
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.
Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this guide was withdrawn in January 2020 in accordance with section 10.6.3 of the Regulations Governing ASTM Technical Committees, which requires that standards shall be updated by the end of the eighth year since the last approval date.
General Information
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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: E2344 − 04 (Reapproved 2011)
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 E1902 Specification for Management of the Confidentiality
and Security of Dictation, Transcription, and Transcribed
1.1 This guide identifies ways to improve the quality of
Health Records (Withdrawn 2011)
healthcare documentation through the dictation process. This
E2117 Guide for Identification and Establishment of a Qual-
guide will assist dictating authors (physicians, physician
ity Assurance Program for Medical Transcription
assistants, nurses, therapists, and other healthcare profession-
E2184 Specification for Healthcare Document Formats
als) in facilitating their use of dictation in the healthcare
(Withdrawn 2011)
environment, that is, hospital, clinic, physician practice, or
multi-campus healthcare system.
3. Terminology
1.2 This guide will aid in the continuity of patient care,
3.1 Definitions:
privacy and confidentiality issues, risk management issues,
3.1.1 analog, n—of, relating to, or being a mechanism in
optimal coding for reimbursement, compliance with legislative
which data is represented by continuously variable physical
and regulatory requirements, and turnaround time.
quantities, that is, recording tape.
1.3 The complexity of the language of medicine, the dy-
3.1.2 blanks, n—missing text that must be filled in as
namicsofthehealthcareenvironment,andthesophisticationof
directed by the dictating author.
the dictation systems present a formidable challenge for
dictating authors. This guide will facilitate a quality dictation
3.1.3 confidential, adj—status accorded to data or informa-
message. tion indicating that it is sensitive, and therefore, it must be
protected against theft, disclosure, or improper use.
1.4 This guide does not address the medical transcription
process. 3.1.4 dictate workstation (or dictate station), n—location
with a device for input of voice dictation.
1.5 This standard does not purport to address all of the
safety concerns, if any, associated with its use. It is the
3.1.5 dictating author, n—one who dictates information to
responsibility of the user of this standard to establish appro-
be transcribed, that is, healthcare students and healthcare
priate safety and health practices and determine the applica-
professionals.
bility of regulatory requirements prior to use.
3.1.6 dictation message (or digital voice file), n—unit of
1.6 This international standard was developed in accor-
information that consists of both audio (voice) and its data
dance with internationally recognized principles on standard-
elements.
ization established in the Decision on Principles for the
3.1.7 document, n—report in any form (print, electronic, or
Development of International Standards, Guides and Recom-
voice file).
mendations issued by the World Trade Organization Technical
Barriers to Trade (TBT) Committee.
3.1.8 healthcare environment, n—any facility whose pri-
mary purpose is delivery of healthcare, that is, hospital, clinic,
2. Referenced Documents
physician practice, or multi-campus healthcare system.
2.1 ASTM Standards:
3.1.9 medical transcription, n—process of interpreting and
transcribing dictation by physicians and other healthcare pro-
fessionals regarding patient assessment, workup, therapeutic
This guide is under the jurisdiction of ASTM Committee E31 on Healthcare
Informatics and is the direct responsibility of Subcommittee E31.15 on Healthcare
procedures, clinical course, diagnosis, prognosis, and so forth
Information Capture and Documentation.
into readable text to document patient care and facilitate
CurrenteditionapprovedJuly1,2011.PublishedJuly2011.Originallypublished
delivery of healthcare services.
2004. Last previous edition approved 2004 as E2344–04. DOI: 10.1520/E2344-
04R11.
For referenced ASTM standards, visit the ASTM website, www.astm.org, or
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 last approved version of this historical standard is referenced on
the ASTM website. www.astm.org.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
E2344 − 04 (2011)
3.1.10 microphone, n—instrument whereby sound waves 4.1.1 Educational facilities for the purpose of introducing
are caused to generate or modulate an electric current usually and training of dictation techniques, and
forthepurposeoftransmittingorrecordingsound(asspeechor
4.1.2 Healthcare professionals for preferred dictation tech-
music). niques.
3.1.11 microphone element, n—diaphragm of the sound-
4.2 Thisdocumentprovidesrecommendationstohelpcreate
collecting source of a microphone.
quality documentation for the following reasons:
3.1.12 quality assurance, n—process of review of a health- 4.2.1 Correct Coding for Reimbursement
care document that will provide adequate confidence that 4.2.1.1 Reports that require no QA intervention increase
dictated patient care documentation is transcribed in a clear,
efficiency of the reimbursement process and reduce discrepan-
consistent, accurate, and complete manner. cies for the healthcare environment and healthcare provider.
4.2.2 Risk Management, Legal, and Peer Review
3.1.13 quality editor, n—personwhoperformsqualityassur-
4.2.2.1 Reports that require no QAintervention reduce legal
ance reviews and/or corrections.
exposure for the healthcare environment and the healthcare
3.1.14 risk management, n—healthcare environment activi-
provider.
ties that identify, evaluate, reduce, and prevent the risk of
4.2.3 Improved TAT
injury and loss to patients, visitors, staff, and the healthcare
4.2.3.1 Reports that require no QA intervention reduce
environment itself.
turnaround time, are more cost-effective, and possibly reduce
3.1.15 speech recognition, n—computerized translation of
delay in patient care.
speech to text.
4.2.4 Legislative and Regulatory Compliance
3.1.16 stat, adj—high priority, or urgent, such as dictation
4.2.4.1 Dictation performed in preferred environments
requiring immediate transcription.
would not compromise patient confidentiality and the patient’s
3.1.17 telephony, n—theuseoroperationofanapparatusfor
right to privacy and would be compliant with legislative and
transmission of sounds between widely removed points with or
regulatory requirements.
without connecting wires.
4.2.5 Continuity of Patient Care
3.1.18 template, n—pattern or guide.
4.2.5.1 Documents with missing text (blanks) compromise
quality.Theseshouldbefilledinorcorrectedasdirectedbythe
3.1.19 text, n—main body of printed or written matter.
dictating author upon authentication of the report.
3.1.20 transcribe, v—see medical transcription.
4.2.6 Improved Communication Between Healthcare Pro-
3.1.21 turnaround time (TAT), n—elapsed time beginning
fessionals
with availability of the voice for transcription and ending when
4.2.6.1 Timely quality documentation can enhance commu-
the transcribed document is available for authentication (see
nication within the dynamic healthcare setting. Patient safety
Guide E2117).
may also be improved when transcribed documents are used to
3.1.22 unique identifier, n—a number used by only one (1)
replace handwritten documentation by healthcare profession-
person that identifies that user.
als.
3.1.23 voiceactivation,n—technologythatallowsrecording
4.3 Thisdocumentdoesnotaddresssecurityissues.Referto
to begin when dictation message begins.
Specification E1902.
3.1.24 voice file, n—digitalized audio portion of a dictation
message.
5. Dictation and Orientation Principles
3.2 Acronyms, Abbreviations, and Short Forms:
5.1 Quality documentation begins with quality dictation.
3.2.1 AAMT—AmericanAssociation for Medical Transcrip-
The quality of transcribed documents is dependent in part on
tion
the quality of the dictation message.
3.2.2 HIPAA—Health Insurance Portability and Account-
5.2 Formal orientation within healthcare environments for
ability Act of 1996
dictating authors makes the process easier and improves the
3.2.3 MR#—medical record number quality of the dictation message (see Guide E2117).
5.2.1 All dictating authors should receive training on the
3.2.4 MT—medical transcriptionist
dictation processes and the overall documentation within their
3.2.5 QA—quality assurance
healthcare environments initially an
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