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【英文标准名称】:StandardGuideforIdentificationandEstablishmentofaQualityAssuranceProgramforMedicalTranscription
【原文标准名称】:医疗记录质量保证计划的鉴定和确立用标准指南
【标准号】:ASTME2117-2006
【标准状态】:现行
【国别】:
【发布日期】:2006
【实施或试行日期】:
【发布单位】:美国材料与试验协会(US-ASTM)
【起草单位】:E31.15
【标准类型】:(Guide)
【标准水平】:()
【中文主题词】:认证;医疗的;医疗技术学;质量;质量保证;记录
【英文主题词】:accuracy;audit;author;consistency;dictatedcontent;dictation;management;medicaltranscription;patientsafety;qualityassurance;review;transcribedcontent
【摘要】:Thisguideliststheessentialcomponentsofaqualityassuranceprogram/qualityimprovementprogramformedicaltranscriptionandisapplicableinallworkenvironments.Itdescribesfactorsthatshouldbeconsideredwhenevaluatingtheindividualsandprocessesresponsibleforproducingpatientcaredocumentationandforestablishingprocedurestoaddressandresolveproblemsthatmayariseindictationandtranscription.Itclarifieswhohastheauthoritytomakedecisionsregardingtranscriptionstyleandeditingandtoresolveconflicts.Thisguidemaybeusedtodevelopaqualityassuranceprogramforindividualmedicaltranscriptionists,medicaltranscriptiondepartmentswithinhealthcareinstitutions,medicaltranscriptionbusinesses,andauthorsofdictation.Aqualityassuranceprogramverifiestheconsistency,correctness,andcompletenessofdictationandtranscribedreports,includingthesystematicidentificationandresolutionofinaccuraciesandinconsistencies,accordingtoorganizationalstandards.Merelyproofreadingreportsisnotequivalenttoaqualityreviewprocess,whichshouldinvolvecomparisonwiththedictationatleastpartofthetimeandreviewformeaningofcontentallofthetime.Qualityisfundamentaltothepatientrecord,andclear,complete,accuratepatientcaredocumentationhelpscontroltherisingcostofhealthcareandcontributestopatientsafety.Thequalityofthefinalreportistheresponsibilityofboththeauthorandthemedicaltranscriptionist.Itistheresultofteamworkbetweenthepersondictatingandtheindividualtranscribing.Itshouldbenotedthatwhileproductionstandardsareimportant,theirvalueisdiminishedifqualityislacking.Likewise,transcribingdictationverbatimmaynotresultinqualitydocumentationorclearcommunication.Itisthetranscriptionistrsquo;responsibilitytorecognize,identify,andreportvoicefilesthatlackaccuracy,completeness,consistency,andclarityforcorrectiveaction.1.1Thisguidecoverstheestablishmentofaqualityassuranceprogramfordictation,medicaltranscription,andrelatedprocesses.Qualityassurance(QA)isnecessarytoensuretheaccuracyofhealthcaredocumentation.Qualitydocumentationprotectshealthcareproviders,facilitatesreimbursement,andimprovescommunicationamonghealthcareproviders,thusimprovingtheoverallqualityofpatientcare.Thisguideestablishesessentialanddesirableelementsforqualityhealthcaredocumentation,butitisnotpurportedtobeanexhaustivelist.1.2TheQApersonnelformedicaltranscriptionshouldhaveanunderstandingoftheprocessesandvariablesoralternativesinvolvedinthecreationofmedicolegaldocumentsandanunderstandingofqualityassuranceissuesastheypertaintomedicaltranscription.Qualifiedpersonnelincludecertifiedmedicaltranscriptionists(CMTs),qualityassuranceprofessionals,orindividualswhoholdotherappropriatelyrelatedcredentialsordegrees.1.3Themedicaltranscriptionist(MT)andQAreviewershouldestablishacooperativepartnershipsothatthereviewoutcomesareobjectiveandeducationaltoincludecorrectiveactionsandremedies.Policiesshouldbedevelopedtominimizesubjectivereview,whichcanleadtoforcefulimplementationofonestyleattheexpenseofotherreasonablechoices.Objectivereview,includinganappealsprocess,shouldfolloworganizationalstandardsthathavebeenagreeduponbythefullteamofQApersonnel,MTs,andmanagementstaff.
【中国标准分类号】:C01
【国际标准分类号】:71_040_50
【页数】:5P.;A4
【正文语种】: