E31.15 - Healthcare Information Capture and Documentation

SIGNIFICANCE AND USE
This guide acknowledges the importance of a well-designed disaster recovery plan that will protect health information and business information from damage, minimize disruption, ensure integrity of data, and provide for orderly recovery.
This guide suggests methods to protect the confidentiality and security of healthcare documentation during a disaster.
It is intended that this guide will contribute to compliance with laws and regulations to improve protection of health information documentation and data integrity with the development of the contingency plan requirement.
This guide will explain key points to include in preparing a disaster recovery plan to resume operations and minimize losses due to unscheduled interruption of critical services if a disaster would occur.
This guide is intended to assist in the development of appropriate policies and procedures that provide protection for individually identifiable health information in a secure environment in the event of a disaster.
SCOPE
1.1 This guide applies across multiple medical transcription settings in which healthcare documents are generated and stored: medical transcription departments, home offices, and medical transcription service organizations (MTSOs). Currently there is no standard disaster recovery plan in the medical transcription industry to provide guidelines for individuals, departments, and businesses to use for designing a disaster recovery plan for their medical transcription environment.
1.2 A disaster is when a sudden event brings great damage, loss, destruction, or interruption of critical services. These guidelines could assist in developing an organized response to reduce the time for loss of services, maintain continuity of workflow, and speed the overall business recovery process.
1.3 This guide supports the HIPAA Security Rule for ensuring data integrity with a contingency plan to include a data backup plan, a disaster recovery plan, and an emergency mode operational plan.  
1.4 This guide is consistent with the requirement for disaster planning and recovery procedures as stated in Guide E 1959.
1.5 This guide is not intended as a disaster recovery plan for Health Information Management Departments or for an entire healthcare facility.

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’responsibility to recognize, identify, and report voice files that lack accuracy, completeness, consistency, and clarity for corre...
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.

SIGNIFICANCE AND USE
This guide provides recommended guidelines for the essential elements to be included in the design and implementation of an efficient, secure, risk-free work environment for medical transcription and health information documentation.
4.1.1 Improve and increase production.
4.1.2 Reduce healthcare costs by minimizing injury/illness.
4.1.3 Increase retention and professional longevity.
4.1.4 Ensure regulatory compliance with state and local government requirements as well as federal privacy and security regulations.
SCOPE
1.1 This guide identifies ways to improve the medical transcription workstation, including, but not limited to, the work environment, which encompasses ergonomics and security issues, equipment, references, and tools.
1.2 This guide will assist healthcare managers, vendors, medical transcription service owners, and individual medical transcriptionists to make informed decisions related to the design of an efficient medical transcription work environment compliant with federal regulatory agencies.
1.3 This guide does not address the medical transcription process or training.
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 limitations prior to use.

SIGNIFICANCE AND USE
This guide is intended to assist healthcare institutions in creating appropriate requests for proposals to be issued for medical transcription services.
This guide provides recommended guidelines for the essential elements to be included in requests for proposals issued to medical transcription services. The purpose of these requests is contracting for the production and delivery of transcribed patient care documentation for a healthcare institution.
This guide recognizes the necessity of a HIPAA Business Associate Agreement.
This guide recognizes the necessity of researching local, state, and federal requirements that may apply.
SCOPE
1.1 This guide covers recommended guidelines to healthcare institutions for the development and issuance of requests for proposals (RFPs), as well as guidelines for medical transcription service organizations (MTSOs) responding to requests for proposals. It does not purport to address all of the legal aspects of the RFP, if any, associated with its use. It is the responsibility of the user of this guide to establish appropriate legal guidelines prior to use.
1.2 It is appropriate for healthcare institutions to issue RFPs from time to time or at regular contractual intervals for the purpose of facilitating the process of contracting for medical transcription services.
1.3 It is anticipated that both a commercial contract for services and a HIPAA Business Associate Agreement will be based upon the responding proposals submitted to the RFP.

SIGNIFICANCE AND USE
This guide is intended to provide general guidelines toward the design and utilization of SRT products used for healthcare documentation. It is intended to recommend the essential elements required of SRT systems in healthcare.
This guide will not identify specific products or make recommendations regarding specific vendors or their products or services.
A well-edited SRT document may result in improved quality over current methods of documentation, that is, handwritten notes and improved productivity over traditional dictation and transcription.
4.3.1 Faster turnaround times.
4.3.2 Legible documentation over handwriting has many advantages:
4.3.2.1 Improved patient care communication.
4.3.2.2 Enhanced patient safety.
4.3.2.3 Reduced malpractice risks.
4.3.2.4 Facilitation of appropriate reimbursement.
4.3.3 For the medical transcriptionist and/or SRMTE, decreased repetitive stress injuries, such as neck, arm, wrist, and heel pain.
4.3.4 Facilitation of cost controls related to document completion.
4.3.5 Better utilization of medical language skills of MTs as productivity is not limited by keyboarding skills.
SCOPE
1.1 This guide identifies system types and describes various features of speech recognition technology (SRT) products used to create the healthcare record. This will assist users (health information professionals, medical report originators, administrators, medical transcriptionists, speech recognition medical transcription editors (SRMTEs), system integrators, support personnel, trainers, and others) to make informed decisions relating to the design and utilization of SRT systems.
1.2 This guide does not address the following items:
1.2.1 System and data (voice and text) security.
1.2.2 Administrative processes such as authentication of the document, productivity measurements, etc.

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.

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. It also assists in protecting 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. 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 departmental standards that have been agreed upon by the full team of QA personnel, MTs, and management staff.

SCOPE
1.1 This guide covers recommended guidelines to healthcare institutions for the development and issuance of requests for proposals, as well as guidelines for medical transcription services responding to RFPs. It does not purport to address all of the legal aspects of a request for proposal, if any, associated with its use. It is the respobsibility of the user of this guide to establish appropriate legal guidelines prior to use.  
1.2 It is appropriate for healthcare institutions to issue requests for proposals (RFPs) from time to time or at regular contractual intervals for the purpose of facilitating the process of contracting for medical transcription services.

SCOPE
1.1 This guide covers a broad description of certain steps that should be taken by those involved in the processes of dictation and transcription of patient care documentation to protect the documentation during its development, maintenance, transmission, storage, and retrieval. Variations or exceptions may be appropriate in special situations or because of particular contractual obligations, institutional rules, or provisions of law or regulation.  
1.2 Patients trust and expect that personal health information will be maintained in a confidential and secure manner. This guide has been developed for the purpose of protecting the confidentiality and security of all forms of dictation, transcription, and transcribed health records of patient care documentation.  
1.3 This guide supports the patient's right to confidential, private, and secure documentation of patient care and identifies procedures for preventing breaches of these patient rights.  
1.4 This guide seeks to identify certain dictation and transcription practices that may increase the risks of breaching confidentiality, infringing on privacy, and violating security of patient care documentation.

SIGNIFICANCE AND USE
4.1 This guide acknowledges the importance of a well-designed disaster recovery plan that will protect health information and business information from damage, minimize disruption, ensure integrity of data, and provide for orderly recovery.  
4.2 This guide suggests methods to protect the confidentiality and security of healthcare documentation during a disaster.  
4.3 It is intended that this guide will contribute to compliance with laws and regulations to improve protection of health information documentation and data integrity with the development of the contingency plan requirement.  
4.4 This guide will explain key points to include in preparing a disaster recovery plan to resume operations and minimize losses due to unscheduled interruption of critical services if a disaster would occur.  
4.5 This guide is intended to assist in the development of appropriate policies and procedures that provide protection for individually identifiable health information in a secure environment in the event of a disaster.
SCOPE
1.1 This guide applies across multiple medical transcription settings in which healthcare documents are generated and stored: medical transcription departments, home offices, and medical transcription service organizations (MTSOs). Currently there is no standard disaster recovery plan in the medical transcription industry to provide guidelines for individuals, departments, and businesses to use for designing a disaster recovery plan for their medical transcription environment.  
1.2 A disaster is when a sudden event brings great damage, loss, destruction, or interruption of critical services. These guidelines could assist in developing an organized response to reduce the time for loss of services, maintain continuity of workflow, and speed the overall business recovery process.  
1.3 This guide supports the HIPAA Security Rule for ensuring data integrity with a contingency plan to include a data backup plan, a disaster recovery plan, and an emergency mode operational plan.2  
1.4 This guide is consistent with the requirement for disaster planning and recovery procedures as stated in Guide E1959.  
1.5 This guide is not intended as a disaster recovery plan for Health Information Management Departments or for an entire healthcare facility.
WITHDRAWN RATIONALE
This guide applies across multiple medical transcription settings in which healthcare documents are generated and stored: medical transcription departments, home offices, and medical transcription service organizations (MTSOs).
Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this guide was withdrawn in January 2023 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.

SIGNIFICANCE AND USE
This guide is intended to assist healthcare institutions in creating appropriate requests for proposals to be issued for medical transcription services.
This guide provides recommended guidelines for the essential elements to be included in requests for proposals issued to medical transcription services. The purpose of these requests is contracting for the production and delivery of transcribed patient care documentation for a healthcare institution.
This guide recognizes the necessity of a HIPAA Business Associate Agreement.
This guide recognizes the necessity of researching local, state, and federal requirements that may apply.
SCOPE
1.1 This guide covers recommended guidelines to healthcare institutions for the development and issuance of requests for proposals (RFPs), as well as guidelines for medical transcription service organizations (MTSOs) responding to requests for proposals. It does not purport to address all of the legal aspects of the RFP, if any, associated with its use. It is the responsibility of the user of this guide to establish appropriate legal guidelines prior to use.
1.2 It is appropriate for healthcare institutions to issue RFPs from time to time or at regular contractual intervals for the purpose of facilitating the process of contracting for medical transcription services.
1.3 It is anticipated that both a commercial contract for services and a HIPAA Business Associate Agreement will be based upon the responding proposals submitted to the RFP.
WITHDRAWN RATIONALE
This guide covers recommended guidelines to healthcare institutions for the development and issuance of requests for proposals (RFPs), as well as guidelines for medical transcription service organizations (MTSOs) responding to requests for proposals. It does not purport to address all of the legal aspects of the RFP, if any, associated with its use. It is the responsibility of the user of this guide to establish appropriate legal guidelines prior to use.
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.

SIGNIFICANCE AND USE
This guide provides recommended guidelines for the essential elements to be included in the design and implementation of an efficient, secure, risk-free work environment for medical transcription and health information documentation.
Improve and increase production.
Reduce healthcare costs by minimizing injury/illness.
Increase retention and professional longevity.
Ensure regulatory compliance with state and local government requirements as well as federal privacy and security regulations.
SCOPE
1.1 This guide identifies ways to improve the medical transcription workstation, including, but not limited to, the work environment, which encompasses ergonomics and security issues, equipment, references, and tools.
1.2 This guide will assist healthcare managers, vendors, medical transcription service owners, and individual medical transcriptionists to make informed decisions related to the design of an efficient medical transcription work environment compliant with federal regulatory agencies.
1.3 This guide does not address the medical transcription process or training.
1.4 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 limitations prior to use.
WITHDRAWN RATIONALE
This guide identifies ways to improve the medical transcription workstation, including, but not limited to, the work environment, which encompasses ergonomics and security issues, equipment, references, and tools.
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.

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.

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...

SIGNIFICANCE AND USE
This guide is intended to provide general guidelines toward the design and utilization of SRT products used for healthcare documentation. It is intended to recommend the essential elements required of SRT systems in healthcare.
This guide will not identify specific products or make recommendations regarding specific vendors or their products or services.
A well-edited SRT document may result in improved quality over current methods of documentation, that is, handwritten notes and improved productivity over traditional dictation and transcription.
Faster turnaround times.
Legible documentation over handwriting has many advantages:
Improved patient care communication.
Enhanced patient safety.
Reduced malpractice risks.
Facilitation of appropriate reimbursement.
For the medical transcriptionist and/or SRMTE, decreased repetitive stress injuries, such as neck, arm, wrist, and heel pain.
Facilitation of cost controls related to document completion.
Better utilization of medical language skills of MTs as productivity is not limited by keyboarding skills.
SCOPE
1.1 This guide identifies system types and describes various features of speech recognition technology (SRT) products used to create the healthcare record. This will assist users (health information professionals, medical report originators, administrators, medical transcriptionists, speech recognition medical transcription editors (SRMTEs), system integrators, support personnel, trainers, and others) to make informed decisions relating to the design and utilization of SRT systems.
1.2 This guide does not address the following items:
1.2.1 System and data (voice and text) security.
1.2.2 Administrative processes such as authentication of the document, productivity measurements, etc.
WITHDRAWN RATIONALE
This guide identifies system types and describes various features of speech recognition technology (SRT) products used to create the healthcare record.
Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this guide was withdrawn in January 2019 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.

ABSTRACT
This specification covers management of the confidentiality and security of dictation, transcription, and transcribed health records to protect the documentation during its development, maintenance, transmission, storage, and retrieval. The dictation security policies and procedures are presented in details. The transcription security policies and procedures are presented in details.
SCOPE
1.1 This specification covers a broad description of certain steps that shall be taken by those involved in the processes of dictation and transcription of healthcare documentation to protect the documentation during its development, maintenance, transmission, storage, and retrieval. Variations or exceptions may be appropriate in special situations or because of particular contractual obligations, institutional policies and rules, or provisions of law or regulation.
1.2 Healthcare clients trust and expect that personal health information will be maintained in a confidential and secure manner. This specification has been developed for the purpose of protecting the confidentiality and security of all forms of dictation, transcription, and transcribed healthcare documentation.
1.3 This specification supports the patient's right to confidential, private, and secure healthcare documentation and identifies procedures for preventing breaches of these patient rights.
1.4 This specification seeks to identify certain dictation and transcription practices that may increase the risks of breaching confidentiality, infringing on privacy, and violating security of healthcare documentation.
WITHDRAWN RATIONALE
Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this Specification was withdrawn in 2011 in accordance with section 10.5.3.1 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.

ABSTRACT
This specification addresses requirements for the headings, arrangement, and appearance of sections and subsections when used within an individual's healthcare documents. This specification will facilitate identification and retrieval of health information in a manner that will enhance the quality and efficiency of health services. Use of this specification in conjunction with XML DTDs (extensible markup language document type definitions) and the EHR (electronic health records) would further enhance efficiency in time and cost. In addition, this specification applies across multiple healthcare settings in which healthcare documents are generated, such as hospitals, clinics, skilled nursing facilities, ambulatory care facilities, outpatient surgery centers, and private healthcare providers' offices. The author of a healthcare document may choose to summarize subsection information within a general section rather than creating subsections.
SCOPE
1.1 This specification addresses requirements for the headings, arrangement, and appearance of sections and subsections when used within an individual's healthcare documents. This specification will facilitate identification and retrieval of health information in a manner that will enhance the quality and efficiency of health services. Use of this specification in conjunction with XML DTDs (extensible markup language document type definitions) and the EHR (electronic health records) would further enhance efficiency in time and cost. This specification applies across multiple healthcare settings in which healthcare documents are generated, such as hospitals, clinics, skilled nursing facilities, ambulatory care facilities, outpatient surgery centers, and private healthcare providers' offices.
1.2 This specification addresses the headings, arrangement, and appearance of sections and subsections of healthcare documents, however generated (dictation/transcription, speech recognition, touch-screen entry, and so forth) and whether displayed electronically or on paper. It does not address the titles of healthcare documents or the content of sections and subsections.
1.2.1 The author of a healthcare document may choose to summarize subsection information within a general section rather than creating subsections.
1.3 The format and content of patient-identifying data are addressed in Guide E 1384.
1.4 Issues of confidentiality and security are addressed in Guide E 1869, Guide E 1902, Guide E 1762, Guide E 1985, Guide E 1986, Guide E 1987, Guide E 1988, Specification E 2084, Guide E 2085, and Guide E 2086, as well as in Specification E 2147.
1.5 Issues of XML DTDs are addressed in Specification E 2182 and Guide E 2183.
WITHDRAWN RATIONALE
Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this Specification was withdrawn in 2011 in accordance with section 10.5.3.1 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.

ABSTRACT
This specification covers the format and content of digitally recorded voice data files and their identifying data. The object is to enable transfer between independent digital dictation systems and workstations, regardless of manufacturer and protocols for ensuring reliability. This specification is specifically targeted for the definition of a message encapsulating both the data elements and actual voice file encoded in a standard compression algorithm. The digital voice file format is Resource Interchange File Format (RIFF). Different digital voice file format shall be: PCM; ITU/CCITT A Law; ITU/CCITT mu Law; OKI ADPCM; IMA (DVI) ADPCM; TrueSpeech; and GSM 610. This specification is specifically targeted for the definition of a message encapsulating both the data elements and actual voice file encoded in a standard compression algorithm.
SCOPE
1.1 This specification covers the format and content of digitally recorded voice data files and their identifying data. The object is to enable transfer between independent digital dictation systems and workstations, regardless of manufacturer and protocols for ensuring reliability. This specification does not cover the transmission of voice data files and their identifying data within digital dictation systems and workstations or their transcription into text files.
1.2 This specification may be applied to either the transmission of data over medium- to high-speed data communication networks or to the transmission of data by recording on, and later playing back from, magnetic or optical digital storage media. It defines the blocked stream of data, called a message, which is transmitted over a network connection or recorded on a storage medium. It does not define the hardware or software network protocols or storage media formats needed for message transmission (for example, see ISO 8072-1986) or the formats used to store data internally by the sender or receiver.
1.3 Since some standardization in storage media format and network protocols would help to promote the exchange of data between computer systems with diverse hardware and software, it is suggested that readily available universal media and formats be used for data exchange when possible.
1.4 Any considerations regarding the security of the digital dictation file or its components as defined herein are outside the scope of this specification. Such measures as encryption of files (either at rest or in transit), authentication of users or originators, assignment and control of file access permissions, and backup or recovery of files which may be necessary to meet institutional policies or governmental regulations are not addressed in this specification. Guidance for security of dictated health records can be found in Guide E 1902.
WITHDRAWN RATIONALE
This specification covers the format and content of digitally recorded voice data files and their identifying data. The object is to enable transfer between independent digital dictation systems and workstations, regardless of manufacturer and protocols for ensuring reliability. This specification does not cover the transmission of voice data files and their identifying data within digital dictation systems and workstations or their transcription into text files.
Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this specificaton was withdrawn in 2010 in accordance with section 10.5.3.1 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.