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.
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This course will provide participants with information regarding the common ethical dilemmas in the Skilled Nursing Facility (SNF) setting and resources to help them become advocates in the SNF setting. Topics covered include how to use your company’s internal resources as well as external resources to advocate for patients.
This is Part 4 of a four-part series. Ethical decision-making, specifically with the aging population, is a hot topic in Speech-Language Pathology. This course will review principles of bioethics and how they apply to SLP practice. Case studies will be utilized to provide additional opportunities for analysis. (Part 1: Course 7965, Part 2: Course 7975, Part 3: Course 7991)
During this one-hour on-line course, Dr. Nancy Helm-Estabrooks will discuss clinical uses of the Cognitive Linguistic Quick Test (CLQT). The lecture will be divided into two major areas for discussion of CLQT applications: the CLQT as an assessment/diagnostic instrument, and the CLQT as a tool for forming treatment decisions. Among the clinical populations addressed will be those with right and left hemisphere strokes, traumatic brain injury, Alzheimer's and Parkinson's disease, and mild cognitive impairment. Both research and clinical evidence that support the utility of the CLQT will be reviewed.
This course will briefly review the salient features of acquired apraxia of speech and the principles of motor learning as they apply to best practice. Treatment approaches will be reviewed with current research findings applied to efficacy. The VAST (Video Assisted Speech Technology) approach will be demonstrated as a therapeutic and a compensatory technique.
In this changing health care environment, the SLP should work closely with the patient in establishing goals that focus on function and aim to achieve the desired, measurable outcome. Medicare guidelines stipulate that services must be provided at a level of complexity requiring the services of a speech-language pathologist. Even when Medicare guidelines are followed in the provision of services, the documentation sometimes does not demonstrate the focus on function or that a skilled service was provided. This course will address how to write measurable, functional goals and provide tips on how to accurately document skilled services.