ANSI/ASTM E2117-2006 医疗记录质量保证计划的鉴定和确立用分类指南

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【英文标准名称】:ClassificationsGuideforIdentificationandEstablishmentofaQualityAssuranceProgramforMedicalTranscription
【原文标准名称】:医疗记录质量保证计划的鉴定和确立用分类指南
【标准号】:ANSI/ASTME2117-2006
【标准状态】:现行
【国别】:美国
【发布日期】:2006-10-24
【实施或试行日期】:
【发布单位】:美国国家标准学会(US-ANSI)
【起草单位】:ASTM
【标准类型】:()
【标准水平】:()
【中文主题词】:鉴定;医疗科学;医疗技术学;公共卫生;质量;质量保证;质量管理;记录
【英文主题词】:Identification;Medicalsciences;Medicaltechnology;Publichealth;Quality;Qualityassurance;Qualitymanagement;Transcriptions
【摘要】:Thisguidecoverstheestablishmentofaqualityassuranceprogramfordictation,medicaltranscription,andrelatedprocesses.Qualityassurance(QA)isnecessarytoensuretheaccuracyofhealthcaredocumentation.Qualitydocumentationprotectshealthcareproviders,facilitatesreimbursement,andimprovescommunicationamonghealthcareproviders,thusimprovingtheoverallqualityofpatientcare.Thisguideestablishesessentialanddesirableelementsforqualityhealthcaredocumentation,butitisnotpurportedtobeanexhaustivelist.TheQApersonnelformedicaltranscriptionshouldhaveanunderstandingoftheprocessesandvariablesoralternativesinvolvedinthecreationofmedicolegaldocumentsandanunderstandingofqualityassuranceissuesastheypertaintomedicaltranscription.Qualifiedpersonnelincludecertifiedmedicaltranscriptionists(CMTs),qualityassuranceprofessionals,orindividualswhoholdotherappropriatelyrelatedcredentialsordegrees.Themedicaltranscriptionist(MT)andQAreviewershouldestablishacooperativepartnershipsothatthereviewoutcomesareobjectiveandeducationaltoincludecorrectiveactionsandremedies.Policiesshouldbedevelopedtominimizesubjectivereview,whichcanleadtoforcefulimplementationofonestyleattheexpenseofotherreasonablechoices.Objectivereview,includinganappealsprocess,shouldfolloworganizationalstandardsthathavebeenagreeduponbythefullteamofQApersonnel,MTs,andmanagementstaff.
【中国标准分类号】:C00
【国际标准分类号】:03_120_10;11_020
【页数】:
【正文语种】:英语