1.1 This guide covers a broad description of certain steps that should be taken by those involved in the processes of dictation and transcription of patient care 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 rules, or provisions of law or regulation.

1.2 Patients trust and expect that personal health information will be maintained in a confidential and secure manner. This guide has been developed for the purpose of protecting the confidentiality and security of all forms of dictation, transcription, and transcribed health records of patient care documentation.

1.3 This guide supports the patient's right to confidential, private, and secure documentation of patient care and identifies procedures for preventing breaches of these patient rights.

1.4 This guide seeks to identify certain dictation and transcription practices that may increase the risks of breaching confidentiality, infringing on privacy, and violating security of patient care documentation.