ASTM E1902-97

Designation: E 1902 – 97 An American National Standard
AMERICAN SOCIETY FOR TESTING AND MATERIALS
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Reprinted from the Annual Book of ASTM Standards. Copyright ASTM
Standard Guide for
Management of the Confidentiality and Security of Dictation,
1,2
Transcription, and Transcribed Health Records
This standard is issued under the fixed designation E 1902; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (e) indicates an editorial change since the last revision or reapproval.
1. Scope 4. Significance and Use
1.1 This guide covers a broad description of certain steps 4.1 Increased use of technology within the healthcare sys-
that should be taken by those involved in the processes of
tem has heightened concerns about the confidentiality and
dictation and transcription of patient care documentation to security of patient care documentation. This guide acknowl-
protect the documentation during its development, mainte-
edges the importance of protecting confidentiality and security
nance, transmission, storage, and retrieval. Variations or ex- of patient care documentation by all individuals associated
ceptions may be appropriate in special situations or because of
with the medical dictation and transcription process.
particular contractual obligations, institutional rules, or provi-
4.2 This guide suggests methods to protect the confidenti-
sions of law or regulation.
ality and security of patient care documentation during the
1.2 Patients trust and expect that personal health informa-
process of dictation and transcription, including maintenance,
tion will be maintained in a confidential and secure manner.
transmission, storage, and retrieval.
This guide has been developed for the purpose of protecting the
4.3 Principally state laws, but also federal laws, govern the
confidentiality and security of all forms of dictation, transcrip-
extent of confidentiality and define the exceptions when
tion, and transcribed health records of patient care documen-
disclosures of health information can be legally required. Third
tation.
party payer rules, institutional rules, and other contractual
1.3 This guide supports the patient’s right to confidential,
provisions also may affect the procedures utilized by medical
private, and secure documentation of patient care and identifies
transcriptionists and other healthcare personnel to maintain the
procedures for preventing breaches of these patient rights.
confidentiality of patient care documentation. There are certain
1.4 This guide seeks to identify certain dictation and tran-
conditions prescribed by law under which disclosure of health
scription practices that may increase the risks of breaching
information is permissible.
confidentiality, infringing on privacy, and violating security of
4.4 There is an increasing volume of litigation against
patient care documentation.
healthcare professionals and institutions involving presumed
breaches of confidentiality. Ensuring the confidentiality of
2. Referenced Documents
health records through appropriate policies, procedures, con-
2.1 ASTM Standards:
tinuing education, and training of healthcare personnel has
E 1762 Guide for Electronic Authentication of Health Care
become an important element of risk management. It is
3
Information
intended that this guide will contribute to improved protection
E 1869 Guide for Confidentiality, Privacy, Access, and Data
of patient care documentation and thereby help to reduce the
Security Principles for Health Information Including
volume of litigation against healthcare professionals.
3
Computer-Based Patient Records
4.5 Policies and procedures adopted to protect patient care
documentation and ensure its authenticity and accuracy should
3. Terminology
apply to all parties who participate in the processes of
3.1 Definitions:
dictation, transcription, maintenance, transmission, storage,
3.1.1 secure environment—free from access by unautho-
and retrieval of that data.
rized persons.
4.6 Although a confidentiality statement and employer
policy are likely to be presented to new medical transcription
employees for review and signature, formal orientation and
1
This guide is under the jurisdiction of ASTM Committee E-31 on Healthcare
continuing education regarding confidentiality, patient privacy,
Informatics and is the direct responsibility of Subcommittee E31.22 on Health
and documentation security should continue. Moreover, such
Information Transcription and Documentation.
statements and policies should also be presented to healthcare
Current edition approved Aug. 10, 1997. Published October 1997.
2
This standard is adapted from “Guidelines on the Confidentiality, Privacy, and
providers or others involved in the process of dictation and
Security of Patient Care Documentation Through the Process of
...