ASTM E2117-06
(Guide)Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription
Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription
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.
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Standards Content (Sample)
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An American National Standard
Designation: E2117 – 06
Standard Guide for
Identification and Establishment of a Quality Assurance
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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* E1902 Specification for Management of the Confidentiality
and Security of Dictation, Transcription, and Transcribed
1.1 This guide covers the establishment of a quality assur-
Health Records
ance program for dictation, medical transcription, and related
E1959 GuideforRequestsforProposalsRegardingMedical
processes. Quality assurance (QA) is necessary to ensure the
Transcription Services for Healthcare Institutions
accuracy of healthcare documentation. Quality documentation
E2344 Guide for Data Capture through the Dictation Pro-
protects healthcare providers, facilitates reimbursement, and
cess
improves communication among healthcare providers, thus
E2502 Guide for Medical Transcription Workstations
improving the overall quality of patient care. This guide
2.2 Other Documents:
establishes essential and desirable elements for quality health-
Public Law 104–191 Health Insurance Portability and Ac-
care documentation, but it is not purported to be an exhaustive
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countability Act of 1996 (HIPAA)
list.
Joint Commission onAccreditation of Healthcare Organiza-
1.2 The QApersonnel for medical transcription should have
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tions (JCAHO) Do Not Use Abbreviation List
an understanding of the processes and variables or alternatives
involved in the creation of medicolegal documents and an
3. Terminology
understanding of quality assurance issues as they pertain to
3.1 Definitions:
medical transcription. Qualified personnel include certified
3.1.1 author, n—the person(s) responsible and accountable
medical transcriptionists (CMTs), quality assurance profes-
for the creation, content, accuracy, and completeness of each
sionals, or individuals who hold other appropriately related
dictated and transcribed event or health record entry.
credentials or degrees.
3.1.2 back-formation, n—a verb formed from a noun, for
1.3 The medical transcriptionist (MT) and QA reviewer
example, dialyze (verb) from dialysis (noun).
should establish a cooperative partnership so that the review
3.1.3 concurrent review, n—quality review of transcribed
outcomes are objective and educational to include corrective
reports performed while listening to dictation and comparing
actions and remedies. Policies should be developed to mini-
transcribed document content. Concurrent review is generally
mize subjective review, which can lead to forceful implemen-
performed before reports are delivered to a patient’s record,
tation of one style at the expense of other reasonable choices.
either in print form or electronically, and before they are made
Objective review, including an appeals process, should follow
available for author signature.
organizational standards that have been agreed upon by the full
3.1.4 corrective action, n—a process used to rectify a
team of QA personnel, MTs, and management staff.
situation or problem.
2. Referenced Documents 3.1.5 medical transcription, n—the process of interpreting
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and transcribing dictation by physicians and other healthcare
2.1 ASTM Standards:
providers regarding patient assessment, workup, therapeutic
E1762 Guide for Electronic Authentication of Health Care
procedures, clinical course, diagnosis, prognosis, etc., into
Information
readable text, whether on paper or on computer, in order to
document patient care and facilitate delivery of healthcare
services. (AAMT Book of Style; E1959)
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This guide is under the jurisdiction of ASTM Committee E31 on Healthcare
3.1.6 originator—see author.
Informatics and is the direct responsibility of Subcommittee E31.15 on Healthcare
Information Capture and Documentation.
Current edition approved Oct. 15, 2006. Published November 2006. Originally
approved in 2000. Last previous edition approved in 2000 as E2117 – 00. DOI:
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10.1520/E2117-06. Available from U.S. Government Printing Office, Superintendent of Dcou-
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For referenced ASTM standards, visit the ASTM website, www.astm.org, or ments, 732 N. Capitol St., N.W., Mail Stop: SDE,Washington, D.C. 20401. See also
contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM http://aspe.hhs.gov/adminsimp.
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Standards volume information, refer to the standard’s Document Summary page on Joint Commission on Accreditation of Healthcare Organizations: www.jca-
the ASTM website. ho.org.
*A Summary of Changes section appears at the end of this stan
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