ASTM E2117 PDF

Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription (Withdrawn 2020)

ASTM E2117 – Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription (Withdrawn 2020)

1.1 This guide covers the establishment of a quality assurance program for dictation, medical transcription, and related processes. Qualityassurance (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 theoverall quality of patient care. This guide establishes essential and desirable elementsfor quality healthcare documentation, but it is not purported to be an exhaustivelist.

1.2 The QA personnel for medical transcription should have an understanding of the processes and variables or alternatives involvedin the creation of medicolegal documents and an understanding of quality assuranceissues as they pertain to medical transcription. Qualified personnel includecertified 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 areobjective and educational to include corrective actions and remedies. Policies should be developed to minimize subjectivereview, which can lead to forceful implementation of one style at the expenseof other reasonable choices. Objective review, including an appeals process,should follow organizational standards that have been agreed upon by the fullteam of QA personnel, MTs, and management staff.