Standard Formatting Unifies Patient Records Across Medical Disciplines
A new standard is being drafted to lay the groundwork for uniform
reporting of patient care documents. When completed, healthcare
professionals who access the proposed Standard Specification
for Formats of Documents in Health Records, can facilitate identification
and retrieval of information in a manner that will enhance the
quality and efficiency of health services.
The draft will be balloted within ASTM. It has a lot of potential
benefits and weve made contact with a number of different disciplines
and institutions that have shown a lot of interest, said Claudia
Tessier, executive director and CEO, American Association for
Medical Transcription, Modesto, Calif., and co-chair of the ASTM
task force that is drafting the guide.
The objective of this standard is to develop guidelines for consistent
section names and structures for healthcare documents, explained
Tessier, who also chairs ASTM Committee E-31 on Healthcare Informatics.
They may then be implemented by caregivers who document health
care. In most cases, however, they will allow the transcriptionist
to reformat dictated information according to the guidelines.
This allows consistent documentation without having to re-train
caregivers. It is estimated that such consistent documentation
will improve the quality of health care. However, one of the obstacles
of creating the standard is to develop a consensus process.
Toward that consensus, Tessier and task force members made contact
with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National
Committee on Quality Assurance, and other organizations. What
we have found is that there is not only interest and support but
weve been urged to extend it beyond transcription, said Tessier.
So whether notes are entered through dictation transcription,
handwritten, direct entry by the care provider, speech recognition,
or whatever form the entry takes, the aim would be for the format
to be consistent in all of those forms and not just in transcription.
Co-chaired by Dr. Paul Schyve, M.D., senior vice president, JCAHO,
the task force includes wide-scale participation from industry,
such as medical transcriptionists, physicians, nurses, as well
as members of government and medical groups. We had a meeting
very early on with representatives from the Department of Health
and Human Services, HCFA [Healthcare Financing Administration],
the Agency on Healthcare Policy and Quality, and others from the
U.S. government, Tessier recalled. So weve had a lot of interest
expressed through government agencies and that would include the
VA [Veterans Administration] and Department of Defense, as well.
Through the assistance of the American Medical Association, the
task force also met with nearly 20 representatives from a variety
of medical societies. We have done a good job of trying to involve
as many stakeholders as possible, she added.
Tessier hopes the guide will be adopted in inpatient and outpatient
settings when completed. Although this standard is not limited
to transcription, transcription is probably the primary and greatest-in-volume
medium for entering information into the record, she said. We
estimate that there are well over a billion reports annually that
are transcribed nationally regarding patient care.
When one works either in an institutional department of transcription,
or for a transcription business that does transcription for multiple
institutions, it is necessary to learn different formats for every
institution, and sometimes for different departments and specific
care providers. So this could not only facilitate better communication
across disciplines about patient condition and therefore improve
patient care but it could also begin to cut the cost associated
with documentation. If one has standards for presenting information
that are consistent across departments and institutions, it will
facilitate greater productivity in documentation.
Questions may be directed to Claudia Tessier, American Association for Medical Transcription, 3460 Oakdale
Rd., Ste. M, Modesto, CA 95357 (209/551-0883; fax: 209/551-1537).
Committee E-31 meets May 6-8 in San Francisco, Calif., in conjunction
with MRI TEPR 2000. For meeting or membership information, contact
E-31 Staff Manager Teresa Cendrowska, ASTM (610/832-9718). //