AAMT(美国医学转录协会)立场文件。供应商的签名。

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引用次数: 0

摘要

医学转录员是医学语言专家,他们抄写听写的病人报告。他们以尽可能完整、清晰、一致和正确的方式解释和编辑原始数据(听写)。医学转录员可以证明他们转录的准确性;他们不能证明它所依据的口述的准确性。如果医疗保健提供者在其签名之前没有对患者记录的内容给予适当的关注,则患者的护理和福祉将面临风险。提供者的签名传达了只有提供者才能提供的记录内容的准确性;因此,授权附加签名是不适当的,不应该被允许。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
AAMT (American Association for Medical Transcription) position paper. Providers' signatures.

Medical transcriptionists are medical language specialists who transcribe dictated patient reports. They interpret and edit raw data (dictation) in as complete, clear, consistent, and correct a manner as possible. Medical transcriptionists can attest to the accuracy of their transcription; they cannot attest to the accuracy of the dictation on which it is based. Patient care and well-being are at risk if proper attention is not given by the healthcare provider to the content of the patient record before the provider's signature is affixed. The provider's signature communicates accuracy of record content that only the provider can give; thus, delegation of authority to affix signatures is inappropriate and should not be allowed.

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