ASTM E2344-2004(2011) Standard Guide for Data Capture through the Dictation Process《通过口述过程获取数的标准取指南》.pdf

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1、Designation: E2344 04 (Reapproved 2011)An American National StandardStandard 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 revis

2、ion, 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. Scope1.1 This guide identifies ways to improve the quality ofhealthcare documentation through the dictation pr

3、ocess. Thisguide will assist dictating authors (physicians, physician assis-tants, nurses, therapists, and other healthcare professionals) infacilitating their use of dictation in the healthcare environment,that is, hospital, clinic, physician practice, or multi-campushealthcare system.1.2 This guid

4、e will aid in the continuity 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 enviro

5、nment, and the sophistication 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, i

6、f any, associated with its use. 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.2. Referenced Documents2.1 ASTM Standards:2E1902 Specification for Management of the Con

7、fidentialityand Security of Dictation, Transcription, and TranscribedHealth Records3E2117 Guide for Identification and Establishment of aQuality Assurance Program for Medical TranscriptionE2184 Specification for Healthcare Document Formats33. Terminology3.1 Definitions:3.1.1 analog, nof, relating to

8、, 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 indicating that it is sensitive

9、, 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 students and healthcareprofe

10、ssionals.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 is delivery of healthcare, t

11、hat 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, clinical course, diagnosis, pr

12、ognosis, and so forthinto readable text to document patient care and facilitatedelivery of healthcare services.3.1.10 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

13、 microphone element, ndiaphragm of the sound-collecting source of 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.1Thi

14、s guide is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.15 on HealthcareInformation Capture and Documentation.Current edition approved July 1, 2011. Published July 2011. Originally published2004. Last previous edition appr

15、oved 2004 as E234404. DOI: 10.1520/E2344-04R11.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.3Withdrawn. Th

16、e last approved version of this historical standard is referencedon www.astm.org.1Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.3.1.13 quality editor, nperson who performs quality as-surance reviews and/or corrections.3.1.14 risk ma

17、nagement, 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, adjhigh priority, or urgent, suc

18、h as dictationrequiring immediate transcription.3.1.17 telephony, nthe use or operation of an apparatusfor transmission of sounds between widely removed pointswith or without connecting wires.3.1.18 template, npattern or guide.3.1.19 text, nmain body of printed or written matter.3.1.20 transcribe, v

19、see 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 one (1)person that identifies that

20、 user.3.1.23 voice activation, ntechnology that allows record-ing to 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 Transcrip-tion3.2.2 HIPAAHealth Insuran

21、ce 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 contribute to quality documen-tat

22、ion, 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 following reasons:4.2.1 Correct C

23、oding 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 require no QA intervention reduce

24、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 Compliance4.2.4.1 Dictation performed in

25、 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 should be filled in or correct

26、ed 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 improved when transcribed documents a

27、re 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 transcribed documents is dependent in

28、 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 thedictation processes and the ov

29、erall 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 guidelines for report turnaround tim

30、es 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.5.2.1.4 Maintain a quiet and secure area for the dictationproces

31、s (see Specification E1902). Advise dictating authors touse the designated dictation areas to avoid background noises,distractions, interruptions and confidentiality issues. Advisedictating authors to avoid eating, gum chewing, yawning,smoking, etc., while dictating. Advise dictating authors toavoid

32、 side conversations and background distractions such asvoices, telephone ringing, and/or music that may obscure thedictation.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 dictationp

33、rocess regarding any mechanical, technical, or other problemsthat may interfere with a clear, complete, and accurate docu-ment (see Guide E2117).5.2.1.7 Explain policies and procedures for dictating anamended report.4Available from U.S. Government Printing Office Superintendent of Documents,732 N. C

34、apitol St., NW, Mail Stop: SDE, Washington, DC 20401.E2344 04 (2011)25.3 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, but are not limited to, the fol

35、lowing: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 distance of others (see Specific

36、ation 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 appropriate work type identifier for

37、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 patients as well as the same pa

38、tient 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 optimal memory recall, perform dict

39、ation 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, patient name or number or bot

40、h,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 all names.5.6 Confidentiality

41、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 informationwithin the text of the report

42、 (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 use the dictation system.5.7.

43、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, storage, and security.6.1.1 Ana

44、log6.1.1.1 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 patient information (see Speci

45、ficationE1902).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 the use of conference mode for

46、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 temperatures, mag-nets, abusi

47、ve 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 areessential for retrieval, TAT, editing, review, etc.(2) Be aware of connection quality and refrain from usingstatic lines

48、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.(5) Complete dictation in timely and secure manner.6.1.2.2 Hand-held Digital Systems(1) Correctly key in appropriate numbers, w

49、hich areessential for retrieval, TAT, editing, review, etc.(2) Safeguard units with dictation to assure confidentialityand privacy of patient information.(3) Refrain from using the voice-activated devices.(4) Indicate end of dictation.(5) Transfer voice files in a timely and secure manner.6.1.3 Speech Recognition Systems6.1.3.1 Correctly key in appropriate numbers, which areessential for retrieval, TAT, editing, review, etc.6.1.3.2 Be aware of microphone placement and connectionquality for optimal sound quality. Use noise-canceling micro-phones.6.1.3.3