This guide lists the essential components of a quality assurance program/quality improvement program for medical transcription and is applicable in all work environments. It describes factors that should be considered when evaluating the individuals and processes responsible for producing patient care documentation and for establishing procedures to address and resolve problems that may arise in dictation and transcription. It clarifies who has the authority to make decisions regarding transcription style and editing and to resolve conflicts. This guide may be used to develop a quality assurance program for individual medical transcriptionists, medical transcription departments within healthcare institutions, medical transcription businesses, and authors of dictation. A quality assurance program verifies the consistency, correctness, and completeness of dictation and transcribed reports, including the systematic identification and resolution of inaccuracies and inconsistencies, according to organizational standards. Merely proofreading reports is not equivalent to a quality review process, which should involve comparison with the dictation at least part of the time and review for meaning of content all of the time. Quality is fundamental to the patient record, and clear, complete, accurate patient care documentation helps control the rising cost of health care and contributes to patient safety. The quality of the final report is the responsibility of both the author and the medical transcriptionist. It is the result of teamwork between the person dictating and the individual transcribing. It should be noted that while production standards are important, their value is diminished if quality is lacking. Likewise, transcribing dictation verbatim may not result in quality documentation or clear communication. It is the transcriptionist's responsibility to recognize, identify, and report voice files that lack accuracy, completeness, consistency, and clarity for corrective action.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.

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4.1 This guide acknowledges the importance of a well-designed disaster recovery plan that will protect health information and business information from damage, minimize disruption, ensure integrity of data, and provide for orderly recovery.4.2 This guide suggests methods to protect the confidentiality and security of healthcare documentation during a disaster.4.3 It is intended that this guide will contribute to compliance with laws and regulations to improve protection of health information documentation and data integrity with the development of the contingency plan requirement.4.4 This guide will explain key points to include in preparing a disaster recovery plan to resume operations and minimize losses due to unscheduled interruption of critical services if a disaster would occur.4.5 This guide is intended to assist in the development of appropriate policies and procedures that provide protection for individually identifiable health information in a secure environment in the event of a disaster.1.1 This guide applies across multiple medical transcription settings in which healthcare documents are generated and stored: medical transcription departments, home offices, and medical transcription service organizations (MTSOs). Currently there is no standard disaster recovery plan in the medical transcription industry to provide guidelines for individuals, departments, and businesses to use for designing a disaster recovery plan for their medical transcription environment.1.2 A disaster is when a sudden event brings great damage, loss, destruction, or interruption of critical services. These guidelines could assist in developing an organized response to reduce the time for loss of services, maintain continuity of workflow, and speed the overall business recovery process.1.3 This guide supports the HIPAA Security Rule for ensuring data integrity with a contingency plan to include a data backup plan, a disaster recovery plan, and an emergency mode operational plan.21.4 This guide is consistent with the requirement for disaster planning and recovery procedures as stated in Guide E1959.1.5 This guide is not intended as a disaster recovery plan for Health Information Management Departments or for an entire healthcare facility.

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This specification covers management of the confidentiality and security of dictation, transcription, and transcribed health records to protect the documentation during its development, maintenance, transmission, storage, and retrieval. The dictation security policies and procedures are presented in details. The transcription security policies and procedures are presented in details.1.1 This specification covers a broad description of certain steps that shall be taken by those involved in the processes of dictation and transcription of healthcare documentation to protect the documentation during its development, maintenance, transmission, storage, and retrieval. Variations or exceptions may be appropriate in special situations or because of particular contractual obligations, institutional policies and rules, or provisions of law or regulation.1.2 Healthcare clients trust and expect that personal health information will be maintained in a confidential and secure manner. This specification has been developed for the purpose of protecting the confidentiality and security of all forms of dictation, transcription, and transcribed healthcare documentation.1.3 This specification supports the patient's right to confidential, private, and secure healthcare documentation and identifies procedures for preventing breaches of these patient rights.1.4 This specification seeks to identify certain dictation and transcription practices that may increase the risks of breaching confidentiality, infringing on privacy, and violating security of healthcare documentation.

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This guide provides recommended guidelines for the essential elements to be included in the design and implementation of an efficient, secure, risk-free work environment for medical transcription and health information documentation.Improve and increase production.Reduce healthcare costs by minimizing injury/illness.Increase retention and professional longevity.Ensure regulatory compliance with state and local government requirements as well as federal privacy and security regulations.1.1 This guide identifies ways to improve the medical transcription workstation, including, but not limited to, the work environment, which encompasses ergonomics and security issues, equipment, references, and tools.1.2 This guide will assist healthcare managers, vendors, medical transcription service owners, and individual medical transcriptionists to make informed decisions related to the design of an efficient medical transcription work environment compliant with federal regulatory agencies.1.3 This guide does not address the medical transcription process or training.1.4 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 limitations prior to use.

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This guide is intended to assist healthcare institutions in creating appropriate requests for proposals to be issued for medical transcription services.This guide provides recommended guidelines for the essential elements to be included in requests for proposals issued to medical transcription services. The purpose of these requests is contracting for the production and delivery of transcribed patient care documentation for a healthcare institution.This guide recognizes the necessity of a HIPAA Business Associate Agreement.This guide recognizes the necessity of researching local, state, and federal requirements that may apply.1.1 This guide covers recommended guidelines to healthcare institutions for the development and issuance of requests for proposals (RFPs), as well as guidelines for medical transcription service organizations (MTSOs) responding to requests for proposals. It does not purport to address all of the legal aspects of the RFP, if any, associated with its use. It is the responsibility of the user of this guide to establish appropriate legal guidelines prior to use.1.2 It is appropriate for healthcare institutions to issue RFPs from time to time or at regular contractual intervals for the purpose of facilitating the process of contracting for medical transcription services.1.3 It is anticipated that both a commercial contract for services and a HIPAA Business Associate Agreement will be based upon the responding proposals submitted to the RFP.

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