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Issue Focus: Writing Orders in the Medical Chart
Treatment Tips | Breaking News | What's New on ASHA.org | Featured Question
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Welcome to Access SLP Health Care, ASHA's bimonthly e-newsletter that addresses the specific needs of speech-language pathologists (SLPs) working in health care. If you have not already subscribed, send a blank e-mail with the word "subscribe" in the subject line to: Access-SLPhealthcare-request@lists.asha.org. If you know colleagues who might enjoy this newsletter, please forward this e-mail.
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Share Your Treatment Tips
Tell us what is working for you and improving the services you provide. Do you use an old tool in a new way? Have you streamlined your documentation? Are you able to manage cancellations and no-shows in your facility? Share what works for you with your colleagues!
Treatment Tip Submission Form
This month's tip comes from Janice Masterson, M.S., CCC-SLP, from the Finger Lakes Health/Geneva General Hospital in Geneva, NY.
To find treatment materials, network with other hospital departments as well as local businesses and others in the community. For example, the hospital pharmacy always gets a lot of "stuff" from pharmaceutical vendors that they can't always use. I am able to get a yearly supply of appointment calendars to use with patients during cognitive rehab tasks, as well as pen lights and pens to use with patients. Area restaurants are often generous with their menus; simply remind them of the free advertising opportunities they get when their information is used by patients during treatment sessions.
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Breaking News!
ASHA Health Care 2008 and Business Institute
Registration now open! Don't miss out on the latest clinical information for SLPs in health care. And the Business Institute is back by popular demand for private practitioners and those working in management and administration.
Latest Medicare Developments
Congress defers Medicare Fee Schedule cuts and therapy caps for 6 months. Read more.
Cultural Competence Corner
New Year's Resolutions:
- Go to the gym every day.
- Continue to develop my cultural competence.
- Organize office filing cabinets.
- Tell at least one joke per day.
Health Care Trend Reports Available
Read more about trends in caseload characteristics and workforce and work conditions in health care settings.
New and Revised ICD-9 Codes Now in Effect
Make sure you are including the appropriate codes in your documentation.
Did You Know About Available Multicultural Resources on ASHA's Web Site?
The Office of Multicultural Affairs (OMA) addresses cultural and linguistic diversity issues related to professionals and persons with communication disorders and differences. Resources include fact sheets, cultural competence information, faculty information, phonemic inventories, and more.
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Featured Question - Writing Orders in the Medical Chart
Can an SLP write orders in the patient's medical chart or take verbal orders from a physician?
In some facilities, SLPs may be asked to write verbal orders from the physician in the chart, or to write diet-texture recommendations or other orders for the physician to sign. In some cases, the physician countersignature may not be required. ASHA has no policies prohibiting the practice of SLPs writing orders. Contact the state agency governing health care to determine what state regulations allow. The facility also should make a determination as to whether this best serves patient care and is an acceptable liability risk.
The Joint Commission on Accreditation of Healthcare Organizations does not specify in their accreditation standards which personnel are able to write orders in the medical chart. The following excerpt from the 2007 Comprehensive Accreditation Manual for Hospitals (CAMH), Management of Information chapter (page IM-12), indicates that the facility should define which personnel are authorized to write in the medical record:
Standard IM.6.10
The hospital has a complete and accurate medical record for patients assessed, cared for, treated, or served.
Elements of Performance for IM.6.10
- Only authorized individuals make entries into the medical record.
- The hospital defines which entries made by non-independent practitioners require countersigning consistent with law or regulation (page IM-12).
Comprehensive Accreditation Manual for Hospitals: The Official Handbook. (2007). Oakbrook Terrace, IL: Joint Commission Resources, Inc.
The Joint Commission does have patient safety regulations about taking verbal orders and abbreviations that are prohibited in medical charts that should be considered in any policy.
Clinicians should be sure that their recommendations are within their scope of practice and do not include information that is not part of their clinical competencies (e.g., caloric requirements, sodium restrictions, etc.). Policies should be written to document the agreed-upon procedure.
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Announcements
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Deadline for Nominations: Jan. 18!
Online nominations are currently being accepted for positions on ASHA's new Board of Directors and Advisory Councils! A complete position description and the online nomination form can be found on ASHA's Web site. Exercise one of your most important member benefits and step up to the plate and nominate!
Funding Opportunity!
Don't miss out on the opportunity for grants for multicultural activities. Keep your eye out for additional announcements and deadlines.
Go Green—Hit the Online Renewal Scene!
Over 50,000 of your ASHA and NSSLHA colleagues renewed online for 2007, and you can too. It's fast, easy, and secure—plus, it's better for the planet. No paper, no stamps, no waste. All you need is your Visa or MasterCard and your ASHA ID number to renew using our secure Web site.
Want to Meet Your Patients' Needs More Effectively?
ProSearch, ASHA's online directory of audiology and speech-language pathology programs, helps consumers find quality services from thousands of programs that employ ASHA certified SLPs and audiologists. Get Discovered! Sign Up for ProSearch—ASHA's Free Referral Service.
Be an Ambassador for the Professions!
Recruitment materials are available for career fairs and presentations.
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Watch for the next issue of Access SLP Health Care in March 2008.
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