scope:

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.

abstract: