Significance and Use

This document provides guidelines for dictation techniques and environments that contribute to quality documentation, that is:

Educational facilities for the purpose of introducing and training of dictation techniques, and

Healthcare professionals for preferred dictation techniques.

This document provides recommendations to help create quality documentation for the following reasons:

Correct Coding for Reimbursement

Reports that require no QA intervention increase efficiency of the reimbursement process and reduce discrepancies for the healthcare environment and healthcare provider.

Risk Management, Legal, and Peer Review

Reports that require no QA intervention reduce legal exposure for the healthcare environment and the healthcare provider.

Improved TAT

Reports that require no QA intervention reduce turnaround time, are more cost-effective, and possibly reduce delay in patient care.

Legislative and Regulatory Compliance

Dictation performed in preferred environments would not compromise patient confidentiality and the patient's right to privacy and would be compliant with legislative and regulatory requirements.

Continuity of Patient Care

Documents with missing text (blanks) compromise quality. These should be filled in or corrected as directed by the dictating author upon authentication of the report.

Improved Communication Between Healthcare Professionals

Timely quality documentation can enhance communication within the dynamic healthcare setting. Patient safety may also be improved when transcribed documents are used to replace handwritten documentation by healthcare professionals.

This document does not address security issues. Refer to Specification E1902 .

1. Scope

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

ASTM Standards

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

E2117 Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription

E2184 Specification for Healthcare Document Formats

Keywords

analog; blanks; confidential; dictate; dictating author; dictation; digital; healthcare documentation; medical transcription; quality assurance; risk management; speech recognition; turnaround time (TAT); voice activation: Dictation systems; Healthcare documentation/delivery/training; Medical transcription;

ICS Code

ICS Number Code 11.020 (Medical sciences and health care facilities in general)

DOI: 10.1520/E2344-04R11

ASTM International is a member of CrossRef.

ASTM E2344