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    ASTM E2117-06(2011)

    Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription (Withdrawn 2020)

    Withdrawn Standard: ASTM E2117-06(2011) | Developed by Subcommittee: E31.15


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    Withdrawn Rationale:

    This guide covers the establishment of a quality assurance program for dictation, medical transcription, and related processes. Quality assurance (QA) is necessary to ensure the accuracy of healthcare documentation. Quality documentation protects healthcare providers, facilitates reimbursement, and improves communication among healthcare providers, thus improving the overall quality of patient care. This guide establishes essential and desirable elements for quality healthcare documentation, but it is not purported to be an exhaustive list.

    Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this guide was withdrawn in January 2020 in accordance with section 10.6.3 of the Regulations Governing ASTM Technical Committees, which requires that standards shall be updated by the end of the eighth year since the last approval date.

    1. Scope

    1.1 This guide covers the establishment of a quality assurance program for dictation, medical transcription, and related processes. Quality assurance (QA) is necessary to ensure the accuracy of healthcare documentation. Quality documentation protects healthcare providers, facilitates reimbursement, and improves communication among healthcare providers, thus improving the overall quality of patient care. This guide establishes essential and desirable elements for quality healthcare documentation, but it is not purported to be an exhaustive list.

    1.2 The QA personnel for medical transcription should have an understanding of the processes and variables or alternatives involved in the creation of medicolegal documents and an understanding of quality assurance issues as they pertain to medical transcription. Qualified personnel include certified medical transcriptionists (CMTs), quality assurance professionals, or individuals who hold other appropriately related credentials or degrees.

    1.3 The medical transcriptionist (MT) and QA reviewer should establish a cooperative partnership so that the review outcomes are objective and educational to include corrective actions and remedies. Policies should be developed to minimize subjective review, which can lead to forceful implementation of one style at the expense of other reasonable choices. Objective review, including an appeals process, should follow organizational standards that have been agreed upon by the full team of QA personnel, MTs, and management staff.



    2. Referenced Documents (purchase separately) The documents listed below are referenced within the subject standard but are not provided as part of the standard.

    ASTM Standards

    E1762 Guide for Electronic Authentication of Health Care Information

    E1902 Specification for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Records

    E1959 Guide for Requests for Proposals Regarding Medical Transcription Services for Healthcare Institutions

    E2344 Guide for Data Capture through the Dictation Process

    E2502 Guide for Medical Transcription Workstations

    Other Documents

    Joint Commission on Accreditation of Healthcare O Do Not Use Abbreviation List Joint Commission on Accreditation of Healthcare Organizations: www.jcaho.org.

    Public Law 104–191


    Referencing This Standard
    Link Here
    Link to Active (This link will always route to the current Active version of the standard.)

    DOI: 10.1520/E2117-06R11

    Citation Format

    ASTM E2117-06(2011), Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription (Withdrawn 2020), ASTM International, West Conshohocken, PA, 2011, www.astm.org

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