1. 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.

2. Referenced Documents (purchase separately) The documents listed below are referenced within the subject standard but are not provided as part of the standard.

ASTM Standards

E1762 Guide for Electronic Authentication of Health Care Information

E1902 Specification for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Records

E1959 Guide for Requests for Proposals Regarding Medical Transcription Services for Healthcare Institutions

E2344 Guide for Data Capture through the Dictation Process

E2502 Guide for Medical Transcription Workstations

Other Documents

Keywords

accuracy; audit; author; consistency; dictated content; dictation; management; medical transcription; patient safety; quality assurance; review; transcribed content: Documents/documentation; Establishment; Identification; Medical transcription; Patient biographical/medical data; Quality assurance (QA)--medical services; Transcribed health records;

ICS Code

ICS Number Code 71.040.50 (Physicochemical methods of analysis)

DOI: 10.1520/E2117-06

ASTM International is a member of CrossRef.