- Documenting Clinical Service Delivery: Writing Style and Lexical Selection
- Guide to Clinical Practice in the Acute Hospital Setting
- Documentation Requirements for Speech-Language Pathologists in Pediatric Hospital-Based Programs
- Documentation Requirements for Speech-Language Pathologists in Early Intervention Programs
- School-Based Augmentative and Alternative Communication Evaluation Reports
- Documentation Requirements in Clinical and Educational Audiology
- Counseling in Communication Disorders
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1. Documenting Clinical Service Delivery: Writing Style and Lexical Selection [PDF, 1.8MB]
Dorian Lee Wilkerson
Abstract: Some clinicians manage to fill a blank page with eloquence and ease; others struggle only to write clinical reports that are lacking in clarity and content. Most skilled writers have developed a writing style that eases the pain of report writing and provides the writer with a strategy for approaching each writing task (Murray, 1991a). This article will discuss the importance of developing a writing style. The article will include strategies for developing a writing style, including ways to use cognitive style theory as a basis fro developing a writing style. Also, constraints on individuality of style in clinical report writing as they relate to service delivery settings, the American Speech-Language-Hearing Association (ASHA) Code of Ethics, and reimbursement issues will be discussed. Throughout the article, the term clinical report will be used collectively to refer to diagnostic reports, progress notes, treatment plans, and treatment summary reports.
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2. Guide to Clinical Practice in the Acute Hospital Setting [PDF, 2.5MB]
Laurel H. Hays
Abstract: The acute care setting is unfamiliar to many speech-language pathologists, and developing competency in this setting is a challenge. This article addresses common medical terminology, medical abbreviations, medical procedures, and the role of health care professionals as some hospital policies and procedures. Additionally, patient care prerequisites, patient care protocols, and documentation are reviewed in detail to facilitate competency in speech-language pathologists desiring to practice in this challenging setting. This article provides an overview of relevant information to assist speech-language pathologists as they become competent clinical practitioners in the acute care setting.
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3. Documentation Requirements for Speech-Language Pathologists in Pediatric Hospital-Based Programs [PDF, 1.6MB]
Lemmietta G McNeilly
Abstract: Medical record documentation is pediatric hospital-based programs encompasses numerous areas. Documentation of services rendered to children in the health care system has been impacted by reimbursement and legislative changes. This article provides an overview of the unique facets of pediatric service delivery in medical settings and their documentation requirements. Documentation of interdisciplinary service delivery that addresses speech, language, and feeding issues is discussed. The reader is provided information concerning the medical record to facilitate the documentation of services. Several documentation samples are provided for illustrative purposes. As services are delivered to the complex pediatric population, it is important for clinicians to communicate clearly and effectively. Timeliness and cultural sensitivity are critical factors that must be addressed consistently in medical record documentation and in communication with others.
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4. Documentation Requirements for Speech-Language Pathologists in Early Intervention Programs [PDF, 1.7MB]
Corine Myers-Jennings
Abstract: Speech-language pathologists who provide assistance to families need to be aware of the procedures and documentation requirements for services provided in the various settings. The purpose of this article is to provide the reader with an overview of the mandates of the public law in early intervention and the impending documentation requirements that professionals will encounter as they work with infants, toddlers, and preschoolers. Speech-language pathologists are an integral component of the assessment and intervention processes of early intervention programs. A description of terms and sample documentation will follow to serve as a guide to those of you who will be or are newly employed in an early intervention program.
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5. School-Based Augmentative and Alternative Communication Evaluation Reports [PDF, 1.2MB]
Doreen M Blischak
Kimberly Ho
Abstract: In this article, the process of report writing following augmentative and alternative communication (AAC) assessment is reviewed. First, issues and terminology specific to AAC assessment are introduced, followed by a discussion of the nature of AAC assessment and the role of assistive technology (AT). Then, the process of feature matching is explained, where students strengths and needs are paired with specific assistive communication device features. Report writing is then described, along with suggestions for securing funding. Finally, several sample AAC reports are provided.
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6. Documentation Requirements in Clinical and Educational Audiology [PDF, 1.5MB]
Diane Scott
Abstract: Regardless of position or setting, all audiologists must be concerned with documentation. This article begins with a discussion of the rationale for appropriate documentation in audiology and a description of the "how" of record keeping, which is followed by a discussion of documentation, based on settings and procedures used by audiologists. Documentation requirements of third-party payers are then reviewed. The final section of the article describes report writing in audiology.
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7. Counseling in Communication Disorders [PDF, 1.8MB]
Diane L Kendall
Abstract: The intent of this article is not to make counselors of speech-language pathologists and audiologists, but instead to provide information that will increase the insight and awareness of clinicians when they communicate with patients and their families. This article will highlight the behavioral, humanistic, and existential models of counseling; considerations when counseling spouses and parents; stages of crisis (e.g. shock, realization, retreat, acknowledgement); issues in cultural diversity; and, finally, the status of counseling in the field of communication disorders.
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