ANSI ASTM E2117-2006 Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription《医疗记录质量保证计划的鉴定和确立用分类指南》.pdf
《ANSI ASTM E2117-2006 Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription《医疗记录质量保证计划的鉴定和确立用分类指南》.pdf》由会员分享,可在线阅读,更多相关《ANSI ASTM E2117-2006 Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription《医疗记录质量保证计划的鉴定和确立用分类指南》.pdf(5页珍藏版)》请在麦多课文档分享上搜索。
1、Designation: E2117 06 (Reapproved 2011)Standard Guide forIdentification and Establishment of a Quality AssuranceProgram for Medical Transcription1This standard is issued under the fixed designation E2117; the number immediately following the designation indicates the year oforiginal adoption or, in
2、the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon () indicates an editorial change since the last revision or reapproval.1. Scope*1.1 This guide covers the establishment of a quality assur-ance program for dictation,
3、medical transcription, and relatedprocesses. Quality assurance (QA) is necessary to ensure theaccuracy of healthcare documentation. Quality documentationprotects healthcare providers, facilitates reimbursement, andimproves communication among healthcare providers, thusimproving the overall quality o
4、f patient care. This guideestablishes essential and desirable elements for quality health-care documentation, but it is not purported to be an exhaustivelist.1.2 The QA personnel for medical transcription should havean understanding of the processes and variables or alternativesinvolved in the creat
5、ion of medicolegal documents and anunderstanding of quality assurance issues as they pertain tomedical transcription. Qualified personnel include certifiedmedical transcriptionists (CMTs), quality assuranceprofessionals, or individuals who hold other appropriatelyrelated credentials or degrees.1.3 T
6、he medical transcriptionist (MT) and QA reviewershould establish a cooperative partnership so that the reviewoutcomes are objective and educational to include correctiveactions and remedies. Policies should be developed to mini-mize subjective review, which can lead to forceful implemen-tation of on
7、e style at the expense of other reasonable choices.Objective review, including an appeals process, should followorganizational standards that have been agreed upon by the fullteam of QA personnel, MTs, and management staff.1.4 This international standard was developed in accor-dance with internation
8、ally recognized principles on standard-ization established in the Decision on Principles for theDevelopment of International Standards, Guides and Recom-mendations issued by the World Trade Organization TechnicalBarriers to Trade (TBT) Committee.2. Referenced Documents2.1 ASTM Standards:2E1762 Guide
9、 for Electronic Authentication of Health CareInformation (Withdrawn 2017)3E1902 Specification for Management of the Confidentialityand Security of Dictation, Transcription, and TranscribedHealth Records (Withdrawn 2011)3E1959 Guide for Requests for Proposals Regarding MedicalTranscription Services f
10、or Healthcare InstitutionsE2344 Guide for Data Capture through the Dictation ProcessE2502 Guide for Medical Transcription Workstations2.2 Other Documents:Public Law 104191 Health Insurance Portability and Ac-countability Act of 1996 (HIPAA)4Joint Commission on Accreditation of Healthcare Organiza-ti
11、ons (JCAHO) Do Not Use Abbreviation List53. Terminology3.1 Definitions:3.1.1 author, nthe person(s) responsible and accountablefor the creation, content, accuracy, and completeness of eachdictated and transcribed event or health record entry.3.1.2 back-formation, na verb formed from a noun, forexamp
12、le, dialyze (verb) from dialysis (noun).3.1.3 concurrent review, nquality review of transcribedreports performed while listening to dictation and comparingtranscribed document content. Concurrent review is generallyperformed before reports are delivered to a patients record,either in print form or e
13、lectronically, and before they are madeavailable for author signature.3.1.4 corrective action, na process used to rectify asituation or problem.1This guide is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.15 on HealthcareIn
14、formation Capture and Documentation.Current edition approved July 1, 2011. Published August 2011. Originallyapproved in 2000. Last previous edition approved in 2006 as E2117 06. DOI:10.1520/E2117-06R11.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Serv
15、ice at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.3The last approved version of this historical standard is referenced onwww.astm.org.4Available from U.S. Government Printing Office, Superintendent ofDcouments
16、, 732 N. Capitol St., N.W., Mail Stop: SDE, Washington, D.C. 20401.See also http:/aspe.hhs.gov/adminsimp.5Joint Commission on Accreditation of Healthcare Organizations: www.jca-ho.org.*A Summary of Changes section appears at the end of this standardCopyright ASTM International, 100 Barr Harbor Drive
17、, PO Box C700, West Conshohocken, PA 19428-2959. United StatesThis international standard was developed in accordance with internationally recognized principles on standardization established in the Decision on Principles for theDevelopment of International Standards, Guides and Recommendations issu
18、ed by the World Trade Organization Technical Barriers to Trade (TBT) Committee.13.1.5 medical transcription, nthe process of interpretingand transcribing dictation by physicians and other healthcareproviders regarding patient assessment, workup, therapeuticprocedures, clinical course, diagnosis, pro
19、gnosis, etc., intoreadable text, whether on paper or on computer, in order todocument patient care and facilitate delivery of healthcareservices. (AAMT Book of Style; E1959)3.1.6 originatorsee author .3.1.7 quality assurance audit, nexamination and reviewof transcribed documents to verify accuracy o
20、f work type,patient and author identification, and that dictated content wasappropriately transcribed and edited, with findings communi-cated to and reviewed with appropriate staff. A quality assur-ance audit is generally performed after reports are delivered toa patients record and may also be call
21、ed a retrospectivereview.3.1.8 quality assurance for medical transcription, ntheprocess of review that is intended to provide adequate confi-dence that dictated patient care documentation is transcribed ina clear, consistent, accurate, complete, and timely manner andthat it satisfies stated or impli
22、ed requirements for dictated andtranscribed documentation of patient care. A quality assuranceprogram may also be called a quality improvement program.3.1.9 remedies, nalternatives for correcting a situation orproblem at the MT or author level.3.1.10 retrospective audit, nquality review of transcrib
23、edreports performed after documents have been released forauthor signature and delivered to a patients record. The voicefile may no longer be available for comparison with thetranscribed documents. It is preferable that retrospective auditbe carried out with voice file.3.1.11 stat, adjof high priori
24、ty, or urgent, such as dictationrequiring immediate transcription and delivery.3.1.12 text expander, ncomputer software that allows afew letters or symbols to be expanded to a phrase or sentencein order to enhance productivity.3.1.13 turnaround time, nelapsed time beginning with theavailability of d
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