ASTM E2117-00

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An American National Standard
Designation: E 2117 – 00
Standard Guide for
Identification and Establishment of a Quality Assurance
Program for Medical Transcription
This standard is issued under the fixed designation E 2117; 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 (e) indicates an editorial change since the last revision or reapproval.
1. Scope E 1902 Guide 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
E 1959 Guide for Requests for Proposals Regarding Medi-
processes. Quality assurance (QA) is necessary to ensure the
cal Transcription Services for Healthcare Institutions
accuracy of healthcare documentation. It also assists in pro-
tecting healthcare providers, facilitates reimbursement, and
3. Terminology
improves communication among healthcare providers, thus
3.1 Definitions:
improving the overall quality of patient care. This guide
3.1.1 abbreviation expander, n—computer software that
establishes essential and desirable elements for quality health-
allows a few letters or symbols to be extended to a phrase or
care documentation, but it is not purported to be an exhaustive
sentence in order to enhance productivity.
list.
3.1.2 author, n—the person(s) responsible and accountable
1.2 The QApersonnel for medical transcription should have
for the creation, content, accuracy, and completeness of each
an understanding of the processes and variables or alternatives
dictated and transcribed event or health record entry.
involved in the creation of medicolegal documents and an
3.1.3 back-formation, n—a verb formed from a noun, for
understanding of quality assurance issues as they pertain to
example, dialyze (verb) from dialysis (noun).
medical transcription. Qualified personnel include certified
3.1.4 concurrent review, n—quality review of transcribed
medical transcriptionists (CMTs), quality assurance profes-
reports performed while listening to dictation and comparing
sionals, or individuals who hold other appropriately related
transcribed document content. Concurrent review is generally
credentials or degrees.
performed before reports are delivered to a patient’s record,
1.3 The medical transcriptionist (MT) and QA reviewer
either in print form or electronically, and before they are made
should establish a cooperative partnership so that the review
available for author signature.
outcomes are objective and educational. Policies should be
3.1.5 medical transcription, n—the process of interpreting
developed to minimize subjective review, which can lead to
and transcribing dictation by physicians and other healthcare
forceful implementation of one style at the expense of other
providers regarding patient assessment, workup, therapeutic
reasonable choices. Objective review, including an appeals
procedures, clinical course, diagnosis, prognosis, etc., into
process, should follow departmental standards that have been
readable text, whether on paper or on computer, in order to
agreed upon by the full team of QA personnel, MTs, and
document patient care and facilitate delivery of healthcare
management staff.
services. (AAMT Book of Style; E 1959)
2. Referenced Documents 3.1.6 originator—see author.
3.1.7 quality assurance audit, n—examination and review
2.1 ASTM Standards:
of transcribed documents to verify accuracy of work type,
E 1762 Guide for Electronic Authentication of Health Care
patient and author identification, and that dictated content was
Information
appropriately transcribed and edited, with findings communi-
cated to and reviewed with appropriate staff.
This guide is under the jurisdiction of ASTM Committee E31 on Healthcare 3.1.8 quality assurance for medical transcription, n—the
Informatics and is the direct responsibility of Subcommittee E31.15 on Health
process of review that is intended to provide adequate confi-
Information Capture and Documentation.
dence that dictated patient care documentation is transcribed in
Current edition approved Dec. 10, 2000. Published December 2000.
a clear, consistent, accurate, complete, and timely manner and
Annual Book of ASTM Standards, Vol 14.01.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
E2117–00
that it satisfies stated or implied requirements for dictated and communication. It is the transcriptionist’s responsibility to edit
transcribed documentation of patient care. dictation for clarity, accuracy, completeness, and consistency,
3.1.9 retrospective review, n—quality review of transcribed thus facilitating communication.
reports performed after documents have been released for
5. Dictation
author signature and delivered to a patient’s record. The
5.1 There are four areas that should be addressed with every
dictation may no longer be available for comparison with the
new author providing dictation, and with all authors at regular
transcribed documents.
intervals, particularly when changes occur in policies, staffing,
3.1.10 stat, adj—of high priority, or urgent, such as dicta-
or equipment, or a combination thereof. These four areas are
tion requiring immediate transcription and delivery.
(1) education and orientation, (2) document identification
3.1.11 turnaround time, n—elapsed time beginning with the
process, (3) dictated content, and (4) confidentiality and
availability of dictation or voice file for transcription and
security.
ending when the transcribed document is delivered for authen-
5.2 Quality assurance of medical transcription begins with
tication. (E 1959)
the author of the dictation. The quality of transcribed docu-
3.1.12 verbatim transcription, n—documentation that has
ments is dependent in part on the quality of dictation. Authors
been transcribed exactly as dictated, without editing for accu-
should be educated and oriented in creating a timely, accurate,
racy, consistency, completeness, or clarity. See The AAMT
and understandable dictated report, with emphasis on avoiding
Book of Style for additional information.
the use or overuse of abbreviations, acronyms, back-
3.2 Acronyms:
formations, coined terms, jargon, profanity, short forms, and
AAMT American Association for Medical Transcription
CMT Certified Medical Transcriptionist
slang.Accuracy and completeness of document content are the
MT Medical Transcriptionist; Medical Transcription
responsibility of the author.
QA Quality Assurance
5.3 Education and Orientation:
RFP Request(s) for Proposals
TAT Turnaround Time 5.3.1 Educationandorientationofauthorsshouldincludean
overview of the report generation process, location and proper
4. Significance and Use
use of equipment, report types and arrangement of content, and
4.1 This guide lists the essential components of a quality
turnaround time requirements. Potential problems and proce-
assurance program for medical transcription and is applicable
dures for their resolution should also be addressed.
in all work environments. It describes factors that should be 5.3.2 To ensure accuracy, completeness, and consistency of
considered when evaluating the individuals and processes
documentation, regulatory requirements and institutional poli-
responsible for producing patient care documentation and for cies and guidelines for report formats and organization of
establishing procedures to address and resolve problems that
content should be followed.
may arise in dictation and transcription. It clarifies who has the 5.3.3 A mechanism for feedback should be provided to the
authority to make decisions regarding transcription style and
author regarding the dictation or the process to ensure that the
editing and to resolve conflicts. author is aware of any problems that may preclude clear,
4.2 This guide may be used to develop a quality assurance
accurate documentation or impede timely transcription. This
program for individual medical transcriptionists, medical tran- includes the choice of a quiet and secure area in which to
scription departments within healthcare institutions, medical
dictate; adequate preparation before beginning the dictation
transcription businesses, and authors of dictation. A quality process; self-identification by spelling name and providing
assurance program verifies the consistency, correctness, and
identification number; proficiency in the use of necessary
completenessofdictationandtranscribedreports,includingthe equipment; and confirmation of patient identifiers by entering
systematic identification and resolution of inaccuracies and
numbers correctly, providing pertinent dates, and accurately
inconsistencies, according to departmental standards. Merely spelling patient names upon accessing the dictation system.
proofreading reports is not equivalent to a quality review
Authors of healthcare documents should also correctly spell
process, which should involve comparison with the dictation at
new or unusual terminology and medications as necessary to
least part of the time and review for meaning of content all of
ensure accurate transcription.Authors should identify referring
the time.
physicians, consultants, and those receiving courtesy copies,
4.3 Quality is fundamental to the patient record, and clear, providing spelling, complete addresses, or other information
complete, accurate patient care documentation helps control
that will facilitate delivery.
the rising cost of health care. The quality of the final report is 5.3.4 Priority of work types relative to dictation time and
the responsibility of both the author and the medical transcrip-
transcription turnaround time should be included as part of the
tionist. It is the result of teamwork between the person orientation process. Turnaround time should be defined and
dictatingandtheindividualtranscribing.Itshouldbenotedthat
expectations clarified. See Guide E 1959 for the definition of
while production standards are important, their value is dimin- turnaround time related to requests for proposals and out-
ished if quality is lacking. Likewise, transcribing dictation
sourced transcription.
verbatim may not result in quality documentation or clear 5.4 Document Identification Process:
5.4.1 Instruction should be provided on the document iden-
tification process, for example, how to access the dictation
system, how to indicate a priority dictation using the appropri-
Tessier, Claudia, The AAMT Book of Style for Medical Transcription,American
Association for Medical Transcription, 1995 (print), 1997 (CD-ROM). ate dictation prompts, how to separate multiple reports in one
E2117–00
session or call-in, and how to recognize technical problems and 6.2.6 MTs should be knowledgeable about the QAprogram,
notify designated personnel, indicating from what location the including the definition of errors, acceptable resources, and the
system is being accessed and the nature of the technical issue. resolution of inconsistencies, errors, and other aberrancies.
5.4.2 The author of dictation should be aware that accurate 6.2.7 MTs should respond to feedback from the quality
and complete input of author identifiers, work type, and patient assurance process in a timely manner.
identifiers promotes efficiency and enhances turnaround, 6.2.8 MTs should have the ability and opportunity to chal-
thereby improving patient care. Dictation of several reports on lenge QA review.
multiple patients using only one patient identifier limits the 6.3 Document Identification Process—MTs should follow
ability to track and locate specified patient documentation. established procedures for verifying author and patient identi-
Entry of incorrect work types often will delay transcription of fication and demographics, resolving inconsistencies according
stat or high-priority reports. to established policies.
5.5 Dictated Content: 6.4 Transcribed Content:
5.5.1 In order to document that the standard of patient care 6.4.1 MTs should demonstrate appropriate and accepted use
and all documentation requirements were met, authors should of grammar, punctuation, and language nuances and structure.
organize record content in a logical fashion and be aware of 6.4.2 MTs should be encouraged to use accepted automated
risk management issues when dictating.Authors should adhere technologies, such as spellcheckers, to help ensure accuracy.
to recommended or required report formats and organization of 6.4.3 MTs should use current resource materials.
content in order to facilitate communication among healthcare 6.4.4 MTs should engage in reasonable research to verify
providers. difficult or questionable content.
5.5.2 Content should be free from asides, profanity, deroga- 6.4.5 MTs should appropriately call attention to dictation
tory, and other inappropriate comments. Such comments may that cannot be translated or terminology that cannot be verified.
be called to the attention of risk management personnel. 6.4.6 MTs should follow established format, style, and
5.5.3 Content should not include extensive use of abbrevia- editing policies, including those related to the use of abbrevia-
tions that obstruct communication. Authors should be aware tions, acronyms, back-formations, coined terms, jargon, pro-
that, when transcribed, abbreviations, acronyms, short forms, fanity, short forms, and slang.
jargon, coined terms, and back-formations may be expanded 6.4.7 MTs should review and proofread documents, making
according to policy or regulations. appropriate corrections and revisions.
5.5.4 Contentshouldnotincludeanyspecificreferencesthat 6.4.8 MTs should follow appropriate risk management poli-
identify the patient. See Guide E 1902. cies, including established procedures for notifying authors of
5.6 Confidentiality and Security—Confidentiality and secu- problems arising within their dictation.
rity of author and patient information should be emphasized. 6.5 Confidentiality and Security:
See Guide E 1902 regarding dictation and transcription confi- 6.5.1 MTs should maintain confidentiality and security of
dentiality and security. patient care documentation. Refer to Guide E 1902 for addi-
tional information.
6. Transcription
6.5.2 MTs should notify appropriate personnel of confiden-
6.1 It should be the medical transcriptionist’s responsibility
tiality and security breaches.
to prepare patient care documents that are as accurate, com-
7. Management
plete, and timely as possible.
6.2 Education and Orientation: 7.1 Managementshouldcoordinatetheintegratedprocess
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