1、Designation:E 1902 02An American National StandardStandard Specification forManagement of the Confidentiality and Security of Dictation,Transcription,and Transcribed Health Records1This standard is issued under the fixed designation E 1902;the number immediately following the designation indicates t
2、he year oforiginal adoption or,in the case of revision,the year of last revision.A number in parentheses indicates the year of last reapproval.Asuperscript epsilon(e)indicates an editorial change since the last revision or reapproval.1.Scope1.1 This specification covers a broad description of certai
3、nsteps that shall be taken by those involved in the processes ofdictation and transcription of healthcare documentation toprotect the documentation during its development,mainte-nance,transmission,storage,and retrieval.Variations or ex-ceptions may be appropriate in special situations or because ofp
4、articular contractual obligations,institutional policies andrules,or provisions of law or regulation.1.2 Healthcare clients trust and expect that personal healthinformation will be maintained in a confidential and securemanner.This specification has been developed for the purposeof protecting the co
5、nfidentiality and security of all forms ofdictation,transcription,and transcribed healthcare documenta-tion.1.3 This specification supports the patients right to confi-dential,private,and secure healthcare documentation andidentifies procedures for preventing breaches of these patientrights.1.4 This
6、 specification seeks to identify certain dictation andtranscription practices that may increase the risks of breachingconfidentiality,infringing on privacy,and violating security ofhealthcare documentation.2.Referenced Documents2.1 ASTM Standards:E 1762 Guide for Electronic Authentication of Health
7、CareInformation2E 1869 Guide for Confidentiality,Privacy,Access,and DataSecurity Principles for Health Information IncludingComputer-Based Patient Records2E 1959 Guide for Requests for Proposals Regarding Medi-cal Transcription Services for Healthcare Institutions2E 1985 Guide for User Authenticatio
8、n and Authorization2E 1986 Guide for Information Access Privileges to HealthInformation2E 1988 Guide for Training of Persons who have Access toHealth Information2E 2017 Guide for Amendments to Health Information2E 2084 Specification for Authentication of Healthcare In-formation Using Digital Signatu
9、res2E 2085 Guide for Security Framework for Healthcare Infor-mation2E 2147 Specification for Audit and Disclosure Logs for Usein Health Information Systems2E 2184 Specification for Healthcare Document Formats22.2Other Documents:Public Law 104-191 Health Insurance Portability and Ac-countability Act
10、of 1996(HIPAA)345 CFR Part 142 Security and Electronic Signature Stan-dards;Proposed Rule,U.S.Department of Health andHuman Services345 CFR,Parts 160-164 Standards for Privacy of Individu-ally Identifiable Health Information;U.S.Department ofHealth and Human Services,Office of the Secretary33.Termin
11、ology3.1 Definitions:3.1.1 author,nthe person originating content for a health-care document.3.1.2 confidential,adjstatus accorded to data or informa-tion indicating that it is sensitive for some reason,andtherefore,it needs to be protected against theft,disclosure,orimproper use,or a combination th
12、ereof,and must be dissemi-nated only to authorized individuals or organizations with aneed to know.E 18693.1.3 confidentiality,nthe property that information is notmade available or disclosed to unauthorized individuals,enti-ties,or processes.45 CFR Part 1423.1.4 individually identifiable health inf
13、ormation,nanyinformation,including demographic information collectedfrom an individual,that(1)is created or received by a healthcare provider,health plan,employer,or health care clearing-house;and(2)relates to the past,present,or future physical ormental health or condition of an individual,the prov
14、ision of1This specification is under the jurisdiction of ASTM Committee E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.22 onHealth Information Transcription and Documentation.Current edition approved June 10,2002.Published July 2002.Originallypublished as E 190297.
15、Last previous edition E 190297.2Annual Book of ASTM Standards,Vol 14.01.3Available from U.S.Government Printing Office,Superintendent of Docu-ments,732 N.Capitol St.,NW,Mail Stop:SDE,Washington,DC 20401.See alsohttp:/aspe.hhs.gov/admnsimp1Copyright ASTM International,100 Barr Harbor Drive,PO Box C70
16、0,West Conshohocken,PA 19428-2959,United States.health care to an individual,or the past,present,or futurepayment for the provision of health care to an individual,and(i)identifies the individual,or(ii)with respect to which thereis a reasonable basis to believe that the information can be usedto identify the individual.Public Law 104-191,Section 1171(6)3.1.5 privacy,nthe right of an individual to be left aloneand to be protected against physical or psychological invasionor misuse of their proper
