ASTM E1902

This specification covers management of the confidentiality and security of dictation, transcription, and transcribed health records to protect the documentation during its development, maintenance, transmission, storage, and retrieval. The dictation security policies and procedures are presented in details. The transcription security policies and procedures are presented in details.

This abstract is a brief summary of the referenced standard. It is informational only and not an official part of the standard; the full text of the standard itself must be referred to for its use and application. ASTM does not give any warranty express or implied or make any representation that the contents of this abstract are accurate, complete or up to date.

1. Scope

1.1 This specification covers a broad description of certain steps that shall be taken by those involved in the processes of dictation and transcription of healthcare documentation to protect the documentation during its development, maintenance, transmission, storage, and retrieval. Variations or exceptions may be appropriate in special situations or because of particular contractual obligations, institutional policies and rules, or provisions of law or regulation.

1.2 Healthcare clients trust and expect that personal health information will be maintained in a confidential and secure manner. This specification has been developed for the purpose of protecting the confidentiality and security of all forms of dictation, transcription, and transcribed healthcare documentation.

1.3 This specification supports the patient's right to confidential, private, and secure healthcare documentation and identifies procedures for preventing breaches of these patient rights.

1.4 This specification seeks to identify certain dictation and transcription practices that may increase the risks of breaching confidentiality, infringing on privacy, and violating security of healthcare documentation.

2. Referenced Documents

E1762 Guide for Electronic Authentication of Health Care Information
E1869 Guide for Confidentiality, Privacy, Access, and Data Security Principles for Health Information Including Computer-Based Patient Records
E1959 Guide for Requests for Proposals Regarding Medical Transcription Services for Healthcare Institutions
E1985 Guide for User Authentication and Authorization
E1986 Guide for Information Access Privileges to Health Information
E1988 Guide for Training of Persons who have Access to Health Information
E2017 Guide for Amendments to Health Information
E2084 Specification for Authentication of Healthcare Information Using Digital Signatures
E2085 Guide for Security Framework for Healthcare Information
E2147 Specification for Audit and Disclosure Logs for Use in Health Information Systems
E2184 Specification for Healthcare Document Formats
45 CFR Part 142 Security and Electronic Signature Standards; Proposed Rule, U.S. Department of Health and Human Services
45 CFR, Parts 160-164 Standards for Privacy of Individually Identifiable Health Information; U.S. Department of Health and Human Services, Office of the Secretary
Public Law 104-191 Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Index Terms

confidentiality; dictation; documentation; identifiable information; medical transcription; security; ICS Number Code 11.020; 35.240.80

Citing ASTM Standards

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