Documentation: Frequently Asked Questions
Do I have to include my credentials (e.g., CCC-SLP) in my signature?
Clinical records are a legal document and the signatures of those entering information should reflect their role within the organization. This helps avoid confusion and helps clarify credentials, as appropriate. ASHA specifies that the official title of the profession is "speech-language pathologist." Thus, this should be the title used for ASHA-certified SLPs, either spelled out or included in the abbreviated credential, CCC-SLP. Facility rules may also specify the need to include information about licensure or additional credentials. SLPs holding an advanced degree in another field, such as psychology or business, should be careful to specify their credentials appropriately. See Use of Graduate Doctoral Degrees by Members and Certificate Holders for more information.
Does the SLP supervisor need to co-sign all documentation completed by a student? What about a Clinical Fellow?
The supervisor of noncertified personnel, including persons in their Clinical Fellowship (CF), should sign all records, unless other requirements are stated. For example, Medicare recognizes ASHA's standards for supervision of CFs, and co-signatures by the supervisor are required only when direct supervision of care has occurred. However, in states that do not license CFs, Medicare views them as students and requires 100% supervision by a licensed SLP. In these instances, the supervising SLP would have to sign all notes as the qualified provider.
In situations where a student may work with more than one supervisor, the supervisor of record for that case would be expected to sign notes and reports.
How long after an evaluation or treatment must I complete my documentation?
ASHA does not specify time frames for completing documentation. However, they may be set by national, state, and accrediting body standards, your facility, or individual payers. Documentation should be completed as soon as is reasonable to ensure accuracy and avoid delays in payment, referrals, or other follow-up.
Can I take documentation home to complete it at night or on the weekend?
The rules regarding taking records off site are made by the facility, based upon relevant laws and regulations. If you are a HIPAA covered entity, it would likely be a HIPAA violation to have paper records in an unsecure place like your car or dining room table. Even electronic records must be secured so that they can be accessed only by authorized personnel and encryption may be necessary in the event that there is a security breach. A discussion with your privacy officer or administrator is needed before removing any documentation from the facility.
Even if you are not covered by HIPAA, the ASHA Code of Ethics states in Principle of Ethics I, Rule M that "Individuals shall adequately maintain and appropriately secure records of professional services rendered, research and scholarly activities conducted, and products dispensed, and they shall allow access to these records only when authorized or when required by law." It is your ethical and professional responsibility to ensure your patients' privacy.
Who "owns" the documentation – the clinician who wrote it or the facility/company?
The answer is situation-specific and highly dependent upon state laws and contract language. For example, if the clinician is an employee then the records likely belong to the employer, be that a hospital, clinic, or private practice. If the clinician is an independent contractor, ownership of the physical record will depend upon contract terms. In situations where the clinician is a partner in the business, ownership of business property may vary by state laws and contract terms.
What do I do when my administrator alters or requests that I alter my documentation?
The proper way to make changes to documentation after the fact is to either create a new entry with the information that has changed or to draw a line through the incorrect information and sign and date the change without removing or obliterating what had been written. Any addendum should include the date the change is being entered into the record and the name and signature of the person making the change, as well as the reason for the change.
If a clinician is asked to change information because it is incorrect or incomplete (e.g., wrong date, wrong treatment goal, or forgot to note something of importance), then using the procedure described above should suffice. If, however, there are other reasons for the change then the clinician needs to consider the legal and ethical implications before making any changes. The ASHA Code of Ethics Principle III states:
D. Individuals shall not misrepresent research, diagnostic information, services rendered, results of services rendered, products dispensed, or the effects of products dispensed.
E. Individuals shall not defraud or engage in any scheme to defraud in connection with obtaining payment, reimbursement, or grants for services rendered, research conducted, or products dispensed.
Clinicians should not misrepresent services or findings as this may constitute fraud and may violate the Code of Ethics and licensure laws. If a clinician has evidence that an administrator or other colleague has altered that clinician's documentation to reflect incorrect information or without properly noting the changes, then the clinician should consider his or her ethical obligation to report the behavior and to protect his or her license and certification.
What do I do when I am asked to complete documentation for a colleague who has moved on when I was not previously involved in the case?
Ideally, clinicians will complete all documentation prior to leaving a job. In reality, however, this is not always possible and facilities should have a process in place for addressing incomplete documentation. It may be possible for another clinician to review prior notes and treatment logs to put together the necessary information. The author should be clearly identified and the facility may want to include a note somewhere in the record about the treating clinician's departure so that it is clear to anyone reviewing the chart. If there is not sufficient information to complete the documentation (such as no record of treatment dates) then the facility should make note of that in the record and report that to payers or other reviewers, as appropriate. Attempting to recreate records without sufficient information should be avoided as it may result in false information and fraudulent billing.
Should I release copies of the test protocols when requested by clients?
Patients (or legal guardians in the case of children) have a right to review their educational and medical records, as allowed by both the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA). They may also have a right to copies of the record; however, limitations on what they can have copied may exist, such as legal restrictions.
One such restriction is copyright laws. Publishers of tests often have copyright restrictions regarding photocopying protocols; such information may be available on the publisher's web site or by contacting the publisher directly. For more information on this issue, see:
Are my informal data tallies (such as check marks for accurate response to help me determine progress) considered part of the medical record?
According to the American Health Information Management Association (AHIMA), source data that is interpreted elsewhere is generally not considered part of the designated record set. Check marks or other informal means of recording data during the treatment session are likely meaningless to anyone other than the treating clinician; however, the interpretation of that data (e.g., "Patient was able to complete cloze sentences with 70% accuracy with minimal cues.") is meaningful and is considered part of the record.