ASTM E2344

1.1 This guide identifies ways to improve the quality of healthcare documentation through the dictation process. This guide will assist dictating authors (physicians, physician assistants, nurses, therapists, and other healthcare professionals) in facilitating their use of dictation in the healthcare environment, that is, hospital, clinic, physician practice, or multi-campus healthcare system.

1.2 This guide will aid in the continuity of patient care, privacy and confidentiality issues, risk management issues, optimal coding for reimbursement, compliance with legislative and regulatory requirements, and turnaround time.

1.3 The complexity of the language of medicine, the dynamics of the healthcare environment, and the sophistication of the dictation systems present a formidable challenge for dictating authors. This guide will facilitate a quality dictation message.

1.4 This guide does not address the medical transcription process.

1.5 This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory requirements prior to use.

2. Referenced Documents

E1902 Specification for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Records
E2117 Guide for Identification and Establishment of Quality Assurance for Medical Transcription
E2184 Specification for Healthcare Document Formats

Index Terms

analog; blanks; confidential; dictate; dictating author; dictation; digital; healthcare documentation; medical transcription; quality assurance; risk management; speech recognition; turnaround time (TAT); voice activation; ICS Number Code 11.020

Citing ASTM Standards

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