The proposed guidelines address four components of quality documentation:
--Dictation;
--Transcriptionist skill level;
--Management—how the system is devised and followed; and
--Quality assurance components.

“Those who follow the guidelines can set up a quality assurance program,” says Linda Byrne, senior director of certification at the American Association for Medical Transcription, a former practicing transcriptionist of 11 years who has worked in certification since 1993. She said the group sought to provide some direction for institutional departments, transcription businesses, and various settings to establish a QA program that evaluates their transcriptionists’ product.

The guide was drafted by a task group of transcriptionists and educators, as well as specialists involved in QA, health information and management systems, led by Byrnes and co-chair Carrie Boatman, a transcription specialist with The Medical Word Co., Sacramento, Calif. The task group is part of Subcommittee E31.22 on Health Information Transcription and Documentation, under Committee E31 on Healthcare Informatics.

The draft states: “Quality assurance is necessary to ensure the accuracy of healthcare documentation. It also assists in protecting healthcare providers, facilitates reimbursement, and improves communication among healthcare providers, thus improving the overall quality of patient care. This document is intended to be a guide for establishing a quality assurance program for dictation, medical transcription, and related processes. It establishes essential and desirable elements for quality healthcare documentation.”

It is expected to be available this fall. Questions may be directed to Linda Byrne, American Association for Medical Transcription, 3460 Oakdale Rd., Ste. M, Modesto, CA 95355 (209/ 551-0883). Committee E31 meets Nov. 3-5 in Los Angeles, Calif. For meeting or membership details, contact manager Teresa Cendrowska, ASTM (610/832-9718). //

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