ANSI ASTM E2344-2004 Standard Guide for Data Capture through the Dictation Process《口述过程中数据收集的指南》.pdf

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1、Designation: E2344 04 (Reapproved 2011)Standard Guide forData Capture through the Dictation Process1This standard is issued under the fixed designation E2344; the number immediately following the designation indicates the year oforiginal adoption or, in the case of revision, the year of last revisio

2、n. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon () indicates an editorial change since the last revision or reapproval.1. Scope1.1 This guide identifies ways to improve the quality ofhealthcare documentation through the dictation process. Thisguide will assist

3、dictating authors (physicians, physicianassistants, nurses, therapists, and other healthcare profession-als) in facilitating their use of dictation in the healthcareenvironment, that is, hospital, clinic, physician practice, ormulti-campus healthcare system.1.2 This guide will aid in the continuity

4、of patient care,privacy and confidentiality issues, risk management issues,optimal coding for reimbursement, compliance with legislativeand regulatory requirements, and turnaround time.1.3 The complexity of the language of medicine, the dy-namics of the healthcare environment, and the sophistication

5、 ofthe dictation systems present a formidable challenge fordictating authors. This guide will facilitate a quality dictationmessage.1.4 This guide does not address the medical transcriptionprocess.1.5 This standard does not purport to address all of thesafety concerns, if any, associated with its us

6、e. It is theresponsibility of the user of this standard to establish appro-priate safety and health practices and determine the applica-bility of regulatory requirements prior to use.1.6 This international standard was developed in accor-dance with internationally recognized principles on standard-i

7、zation 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:2E1902 Specification for Management of the Confident

8、ialityand Security of Dictation, Transcription, and TranscribedHealth Records (Withdrawn 2011)3E2117 Guide for Identification and Establishment of a Qual-ity Assurance Program for Medical TranscriptionE2184 Specification for Healthcare Document Formats(Withdrawn 2011)33. Terminology3.1 Definitions:3

9、.1.1 analog, nof, relating to, or being a mechanism inwhich data is represented by continuously variable physicalquantities, that is, recording tape.3.1.2 blanks, nmissing text that must be filled in asdirected by the dictating author.3.1.3 confidential, adjstatus accorded to data or informa-tion in

10、dicating that it is sensitive, and therefore, it must beprotected against theft, disclosure, or improper use.3.1.4 dictate workstation (or dictate station), nlocationwith a device for input of voice dictation.3.1.5 dictating author, none who dictates information tobe transcribed, that is, healthcare

11、 students and healthcareprofessionals.3.1.6 dictation message (or digital voice file), nunit ofinformation that consists of both audio (voice) and its dataelements.3.1.7 document, nreport in any form (print, electronic, orvoice file).3.1.8 healthcare environment, nany facility whose pri-mary purpose

12、 is delivery of healthcare, that is, hospital, clinic,physician practice, or multi-campus healthcare system.3.1.9 medical transcription, nprocess of interpreting andtranscribing dictation by physicians and other healthcare pro-fessionals regarding patient assessment, workup, therapeuticprocedures, c

13、linical course, diagnosis, prognosis, and so forthinto readable text to document patient care and facilitatedelivery of healthcare services.1This guide is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.15 on HealthcareInform

14、ation Capture and Documentation.Current edition approved July 1, 2011. Published July 2011. Originally published2004. Last previous edition approved 2004 as E234404. DOI: 10.1520/E2344-04R11.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serv

15、iceastm.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.Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, P

16、A 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 issued by the World Trade Organization

17、Technical Barriers to Trade (TBT) Committee.13.1.10 microphone, ninstrument whereby sound wavesare caused to generate or modulate an electric current usuallyfor the purpose of transmitting or recording sound (as speech ormusic).3.1.11 microphone element, ndiaphragm of the sound-collecting source of

18、a microphone.3.1.12 quality assurance, nprocess of review of a health-care document that will provide adequate confidence thatdictated patient care documentation is transcribed in a clear,consistent, accurate, and complete manner.3.1.13 quality editor, nperson who performs quality assur-ance reviews

19、 and/or corrections.3.1.14 risk management, nhealthcare environment activi-ties that identify, evaluate, reduce, and prevent the risk ofinjury and loss to patients, visitors, staff, and the healthcareenvironment itself.3.1.15 speech recognition, ncomputerized translation ofspeech to text.3.1.16 stat

20、, adjhigh priority, or urgent, such as dictationrequiring immediate transcription.3.1.17 telephony, nthe use or operation of an apparatus fortransmission of sounds between widely removed points with orwithout connecting wires.3.1.18 template, npattern or guide.3.1.19 text, nmain body of printed or w

21、ritten matter.3.1.20 transcribe, vsee medical transcription.3.1.21 turnaround time (TAT), nelapsed time beginningwith availability of the voice for transcription and ending whenthe transcribed document is available for authentication (seeGuide E2117).3.1.22 unique identifier, na number used by only

22、one (1)person that identifies that user.3.1.23 voice activation, ntechnology that allows recordingto begin when dictation message begins.3.1.24 voice file, ndigitalized audio portion of a dictationmessage.3.2 Acronyms, Abbreviations, and Short Forms:3.2.1 AAMTAmerican Association for Medical Transcr

23、ip-tion3.2.2 HIPAAHealth Insurance Portability and Account-ability Act of 199643.2.3 MR#medical record number3.2.4 MTmedical transcriptionist3.2.5 QAquality assurance3.2.6 TATturnaround time4. Significance and Use4.1 This document provides guidelines for dictation tech-niques and environments that c

24、ontribute to qualitydocumentation, that is:4.1.1 Educational facilities for the purpose of introducingand training of dictation techniques, and4.1.2 Healthcare professionals for preferred dictation tech-niques.4.2 This document provides recommendations to help createquality documentation for the fol

25、lowing reasons:4.2.1 Correct Coding for Reimbursement4.2.1.1 Reports that require no QA intervention increaseefficiency of the reimbursement process and reduce discrepan-cies for the healthcare environment and healthcare provider.4.2.2 Risk Management, Legal, and Peer Review4.2.2.1 Reports that requ

26、ire no QA intervention reduce legalexposure for the healthcare environment and the healthcareprovider.4.2.3 Improved TAT4.2.3.1 Reports that require no QA intervention reduceturnaround time, are more cost-effective, and possibly reducedelay in patient care.4.2.4 Legislative and Regulatory Compliance

27、4.2.4.1 Dictation performed in preferred environmentswould not compromise patient confidentiality and the patientsright to privacy and would be compliant with legislative andregulatory requirements.4.2.5 Continuity of Patient Care4.2.5.1 Documents with missing text (blanks) compromisequality. These

28、should be filled in or corrected as directed by thedictating author upon authentication of the report.4.2.6 Improved Communication Between Healthcare Pro-fessionals4.2.6.1 Timely quality documentation can enhance commu-nication within the dynamic healthcare setting. Patient safetymay also be improve

29、d when transcribed documents are used toreplace handwritten documentation by healthcare profession-als.4.3 This document does not address security issues. Refer toSpecification E1902.5. Dictation and Orientation Principles5.1 Quality documentation begins with quality dictation.The quality of transcr

30、ibed documents is dependent in part onthe quality of the dictation message.5.2 Formal orientation within healthcare environments fordictating authors makes the process easier and improves thequality of the dictation message (see Guide E2117).5.2.1 All dictating authors should receive training on the

31、dictation processes and the overall documentation within theirhealthcare environments initially and when changes occur inpolicies or equipment.5.2.1.1 Address any regulatory requirements and institu-tional policies and guidelines for report formats and organiza-tion of content.5.2.1.2 Provide guidel

32、ines for report turnaround times andthe appropriate use of a stat designation for prioritizing reports.5.2.1.3 Use only facility-approved abbreviations within thedictating message and avoid the use of other abbreviations,jargon, slang, acronyms, and/or coined terms.4Available from U.S. Government Pr

33、inting Office Superintendent of Documents,732 N. Capitol St., NW, Mail Stop: SDE, Washington, DC 20401.E2344 04 (2011)25.2.1.4 Maintain a quiet and secure area for the dictationprocess (see Specification E1902). Advise dictating authors touse the designated dictation areas to avoid background noises

34、,distractions, interruptions and confidentiality issues. Advisedictating authors to avoid eating, gum chewing, yawning,smoking, etc., while dictating. Advise dictating authors toavoid side conversations and background distractions such asvoices, telephone ringing, and/or music that may obscure thedi

35、ctation.5.2.1.5 Advise dictating authors to avoid profanity and/orderogatory, and other inappropriate comments while dictating.5.2.1.6 Include the feedback system about the dictationprocess regarding any mechanical, technical, or other problemsthat may interfere with a clear, complete, and accurate

36、docu-ment (see Guide E2117).5.2.1.7 Explain policies and procedures for dictating anamended report.5.3 Use conversational speed and volume for optimal dic-tation message.5.4 Instruct dictating authors on the functions of the dicta-tion system used within their healthcare environment. Theseinclude, b

37、ut are not limited to, the following:5.4.1 Use of the pause mechanism, use of the review mode,use of the insertion mode.5.4.2 Use of the types of phones used for dictating. Refrainfrom using speaker phones, portable phones, cell phones,public phones, and other recording devices when withinhearing di

38、stance of others (see Specification E1902).5.4.3 Use of microphone settings to avoid clipped wordsand phrases, proper distance of microphone and microphoneelement from mouth.5.4.4 Use of assigned unique identifier for each dictator toassure appropriate access to dictation system.5.4.5 Use of appropr

39、iate work type identifier for appropriatepriority of reports. Use of a stat identifier specifically for statdictation.5.4.6 Proper separation and patient identification of indi-vidual reports dictated within one session.5.4.6.1 One separate dictation for each completed documentseparating different p

40、atients as well as the same patient with adifferent procedure or report type (See Note 1).NOTE 1This reduces misfiled information, which may result inre-dictation.5.5 Report Types and Format of Contents5.5.1 Use standardized headings or templates or both (referto Specification E2184).5.5.2 For optim

41、al memory recall, perform dictation in atimely manner from the patient encounter.5.5.3 Have all pertinent information available during timeof dictation.5.5.4 Provide any special instructions at the beginning ofdictation.5.5.5 At the beginning of each dictation, state dictatingauthor name and number,

42、 patient name or number or both,type/title of report, appropriate dates, and any other informa-tion pertinent to the healthcare record as required by environ-ment.5.5.6 Provide complete names, addresses, and courtesycopy information.5.5.7 Provide correct spelling for new or unusual terminol-ogy and

43、all names.5.6 Confidentiality and Security5.6.1 Dictate only in an environment that will maintainpatient confidentiality and security of healthcare information incompliance with legislative and regulatory requirements (seeSpecification E1902).5.6.2 Avoid the use of any patient-identifying informatio

44、nwithin the text of the report (see Specification E1902).5.7 Unique Identifiers5.7.1 Each individual authorized to dictate shall use uniqueidentifiers to assure appropriate dictation system access (seeSpecification E1902).5.7.2 Document procedures to disable access for persons nolonger authorized to

45、 use the dictation system.5.7.3 An identifier serves as a permanent record and shouldnot be reassigned to another individual.6. Mechanisms to Capture Dictation6.1 Dictating authors may use one or more of severaldifferent methods and should be familiar with the equipmentthey use including handling, s

46、torage, and security.6.1.1 Analog6.1.1.1 Store in protective case with appropriate labeling.6.1.1.2 Erase tapes before using again.6.1.1.3 Replace tapes every three months to avoid breakageand reduced recording quality.6.1.1.4 Safeguard tapes with dictation to assure confidenti-ality and privacy of

47、patient information (see SpecificationE1902).6.1.1.5 Refrain from using the voice-activated equipment.6.1.1.6 Use the correct tape speed (4.8 for standard sizerecorders, 2.4 for microcassettes).6.1.1.7 Store tapes in a secure environment to ensureunauthorized access is avoided.6.1.1.8 Refrain from t

48、he use of conference mode for sensi-tivity issues.6.1.1.9 Always begin dictation at the beginning of side Aand indicate if side B is used.6.1.1.10 Indicate end of dictation.6.1.1.11 Tapes greater in length than 60 min (30 min eachside) compromise TAT and quality.6.1.1.12 Keep tapes away from extreme

49、 temperatures,magnets, abusive handling, etc.6.1.1.13 Deliver tapes with dictation in a timely and securemanner.6.1.2 Digital6.1.2.1 Telephony-based Systems(1) Correctly key in appropriate numbers, which are essen-tial for retrieval, TAT, editing, review, etc.(2) Be aware of connection quality and refrain from usingstatic lines for optimal sound quality.(3) Cell phones and portable phones should be avoidedwhen within hearing distance of others (see SpecificationE1902).(4) Indicate end of dictation.E2344 04 (2011)3(5) Complete dictation in timely and