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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 we’ve 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 we’ve 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 we’ve 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). //