Many are familiar with the mantra, "If it isn't written, it didn't happen." Documentation of services is critical for ensuring continuity of care and reimbursement of services rendered. An often-quoted statement reminds us that, "Excellent record keeping does not guarantee good care, but poor record keeping poses an obstacle to clinical excellence" (Kibbee & Lilly, 1989, p. 16).
Maintaining and securing documentation are largely guided by state requirement as well as by the accrediting agency of the facility. The Medical Records department of a facility should be able to provide specific guidance about procedures and requirements. In general, however, documentation must be maintained as part of the patient's medical record and must be available to auditing bodies upon request. This article will highlight best practice in documentation and also current regulatory guidelines for documentation.
The American Speech-Language-Hearing Association Code of Ethics, to which all speech-language pathologists (SLPs) are bound, is critical to know. Principle of Ethics I, Sections F and K are pertinent to the discussion of documentation.
Principles of Ethics I, Section F specifies:
Individuals shall fully inform the persons they serve of the nature and possible effects of services rendered and products dispensed, and they shall inform participants in research about the possible effects of their participation in research conducted. (American Speech-Language-Hearing Association, 2003b)
This principle suggests that services rendered should be documented as part of the patient's medical record, as part of the evaluation/plan of treatment, or as a separate document, which is subsequently signed by the patient's responsible party.
Principles of Ethics I, Section K, further specifies:
Individuals shall adequately maintain and appropriately secure records of professional services rendered, research and scholarly activities conducted, and products dispensed and shall allow access to these records only when authorized or when required by law. (American Speech-Language-Hearing Association, 2003b)
This principle also suggests that services rendered should be documented as part of the patient's medical record. Documentation is considered best practice by the American Speech-Language-Hearing Association.
Since different areas of the country are reviewed by different fiscal intermediaries (FIs), Medicare audit contractors (MACs), and recovery audit contractors (RACs), and states have different requirements based on licensure law, it is important to be familiar with specific guidelines issued by those regulatory bodies. However, among these agencies there are general guidelines to follow.