Clinical Record Keeping in Audiology and Speech-Language Pathology

I. The Documentor (Who)

1. Usually person who renders the assessment, care, or treatment

2. In emergency situation, person designated to document detailed account of situation

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II. Components of Clinical Record Keeping (What)

1. Identifying information

   1. Facility name and client's clinic or medical record number

   2. Client name and related identifying data (address, telephone number, date of birth, and caretaker or legally responsible person to whom information can be released)

   3. Client insurance or social security number

   4. Referring physician's name, certification, and related identifying information (e.g., Universal Physician Identification Number). Medicare and most private insurance companies require this information.

   5. Professional service (speech-language pathology or audiology) provider's name, certification, and related identifying information

   6. Referral source, related identifying information, reason for referral and date (if applicable)

   7. Billing period (usually a 30-day cycle for most private insurance companies and Medicare)

   8. Date report is prepared and evaluation date

2. Client History (including documents from other sources, such as medical records, education records, previous evaluation reports, etc.)

   1. Medical diagnosis(es) (primary, secondary, including date[s] of onset)

   2. Communication disorder diagnosis (primary, receiving more than 50% of intervention, and secondary, receiving less than 50% of intervention), and onset date(s)

   3. Medical history (pertinent to speech, language, or hearing treatment), including surgical procedures

   4. Education status/occupational status (as appropriate)

   5. Prior functional communication status

   6. Prior speech, language, or hearing treatment and outcome of that treatment

   7. Length of treatment in prior settings

   8. Additional pertinent information (e.g., medical records, psychological reports, educationl tests and observations)

   9. Source(s) of client history

3. Assessment of Current Client Status

   1. Date of initial assessment/reassessment

   2. Initial functional status of client in present facility based upon:

      1. Baseline testing (using standardized and nonstandardized measures)

      2. Interpretation of test scores/results

      3. Other clinical findings (including those from other specialists)

   3. Documentation that speech-language pathology evaluations consider a client's hearing status and that audiology evaluations consider a client's speech-language status in order to determine if referral to the other professional is necessary

   4. Statement of prognosis

   5. Recommendations based on the client's functional needs (including referrals as appropriate)

   6. Signature and title of qualified professional responsible for the assessment (and that of the documentor, if different)

4. Treatment Plan

   1. Date plan of treatment established

   2. Short- and long-term functional communication goals (should reflect desired client outcomes: the level of communication independence the client is expected to achieve based on input from the client and/or family)

   3. Treatment objectives

   4. Recommended type and expected amount (e.g., 1-hour session), frequency (e.g., three times per week), and duration (e.g., 9 months) of present treatment. (Medicare requires documentation of the expected duration of treatment. This information can be revised as needed with rationale for a change in expected duration.)

   5. Follow-up activities

   6. Statement of prognosis

   7. Date treatment plan was discussed with client and/or family

   8. Date interdisciplinary conferences were held

   9. Statement of the schedule for review of the plan

   10. Signature and title of qualified professional responsible for treatment plan (and that of the documentor, if different)

5. Documentation of Treatment

   1. Date client began treatment at present facility

   2. Time period covered by the report

   3. Summaries of assessment and treatment plan in treatment reports

   4. Number of times to date that treatment was rendered in present facility and length of sessions

   5. Current client status: communication diagnosis and objective measures of client communication performance in functional terms that relate to treatment goals (e.g., pre- and post-testing with interpretation of test scores, using same or comparable measures to those used in original assessment)

   6. Any changes in prognosis (include significant developments)

   7. Any changes in plan of treatment

   8. Follow-up recommendations (if client is discharged) or description of need for continued intervention

   9. Signature and title of qualified professional responsible for treatment services (and that of the documentor, if different) Note: The supervisor of noncertified personnel, including persons in Clinical Fellowship (CF), must sign all records. (Medicare recognizes ASHA's standards for supervision of persons in CF. Therefore, cosignatures by the supervisor are required only when direct supervision of care has occurred.) It is suggested that the supervisor co-sign evaluation and discharge summary reports.

6. Record of Consultation

   1. Consultation with other professionals

   2. Consultation with client and caretakers or legally responsible party (or parties)

7. Correspondence pertinent to the individual client

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III. Storage (Where)

1. General Information

   1. In secure place, to be accessed only by authorized personnel

   2. Safeguarded against loss or destruction

2. Current clinical records

   1. In accessible place

3. Historical clinical records

   1. Transferred to microfilm

   2. Maintained through computer storage

   3. In secure yet less accessible place (away from current files)

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IV. Time Frame for Recording, Sending, and Retaining Information (When)

1. Recording

   1. According to time frame set by:

      1. National, state, community, and accrediting body standards

      2. Facility

      3. Department

      4. Common sense (typically, as soon after the event as possible)

2. Sending Reports and Information to Other Professionals

   1. According to a specified time frame (typically, 15 working days) for sending information to other professionals re:

      1. Inpatient/outpatient reports

      2. Evaluation/progress/discharge reports

   2. According to specified time frame (typically, 15 working days) for releasing information to client, caregiver, or other legally responsible party

3. Storage and Maintenance

   1. Current clinical records

      1. Computerized records—according to routine procedure for backing up computerized records (e.g., every night)

      2. Files — when not in use should be stored in a secure yet accessible manner

   2. Historical clinical records

      1. According to schedule for filing and transferring historical files (e.g., to microfilm) for archival storage

      2. According to state law or when no law exists, a created policy that reflects client/patient and program needs—i.e., 5–7 years (some records may need to be kept permanently)? In the absence of a pertinent state statute, Medicare's record retention requirements are the same as the state of Maryland; ^[1] however, client or parent notification does not permit earlier destruction of medical records. Program record keeping procedures may vary. Some programs may use electronic storage. Some facilities may require that this information be maintained in a central medical storage unit. Regardless of storage system, accurate, complete, and accessible information is necessary for good organization and maintenance of records.

      3. Disposal of obsolete records should be in a manner that protects the confidentiality of client information.

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V. Rationale for Documentation (Why)

1. Reasons for appropriate documentation (see JCAHO, 1992):

   1. Justify entry into treatment

   2. Justify continued treatment

   3. Support the diagnosis and treatment

   4. Describe client progress

   5. Describe client response to intervention(s)

   6. Justify discharge from care

   7. Support reimbursement

2. Additional reasons for appropriate documentation:

   1. Facilitate continuous quality improvement

   2. Use as basis for the planning and continuity of evaluation

   3. Justify clinical decisions

   4. Document communication between involved parties (practitioners, client, caregiver, or legally responsible party [parties])

   5. Protect legal interests of client, service provider, and facility

   6. Provide data for continuing education.

   7. Provide data for research (i.e., efficacy)

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VI. Methods (How)

1. Clinical record keeping should:

   1. Conform to federal, state, and local laws

   2. Adhere to facility's standards and regulations

2. Writing should be clearly understood by the reader; that is, content should be:

   1. Accurate, concise, and informative

   2. Adapted for a potentially large readership

   3. Useful and relevant to other staff (i.e., so that anyone can pick up record and continue treatment)

   4. Neat and legible

3. Clinical records should be consistent in format and style:

   1. As established by facility (e.g., SOAP note format—subjective, objective, assessment, plan [Miller & Groher, 1990])

   2. Using codes from International Classification of Diseases-Clinical Modification (ICD-CM), current revision (U.S. Department of Health and Human Services, 1991)

   3. Using procedural codes from Physicians' Current Procedural Terminology (CPT), current edition, when appropriate (American Medical Association, 1993)

   4. Using appropriate terms per ASHA's Classification of Speech-Language Pathology and Audiology Procedures and Communication Disorders (ASHA, 1987)

4. Clinical records need to be organized with entries recorded chronologically

   1. Rather than leaving spaces to fill in at a later time, flagging the entry and charting it out of sequence is better than leaving a blank space to fill in at a later time.

   2. Entering only what has taken place, not anticipated activities or observations

   3. Maintaining continuity

5. Clinical record keeping should be simplified when possible, using:

   1. Flowsheets or checklists to streamline (these do not substitute for detailed documentation of assessments and interventions)

   2. Current symbols or abbreviations (constantly updated) from an approved facility list

   3. A printout of the face sheet when file is computerized (for use in recording information during client visit)

   4. Description of intervention as “treatment according to treatment plan” when this statement accurately describes planned activities

6. The documentor must assure accuracy by:

   1. Proofreading documentation to verify that it says what was meant

   2. Appropriately correcting an entry (i.e., crossing out incorrect material with one line, writing reason for change, entering the correct information, and dating and initialing the correction)

7. The documentor should provide rationale for such clinical decisions as test selection, diagnosis, prognosis, treatment goals, and recommendations. For example, rationale for treatment should be stated to reflect:

   1. Whether medical diagnosis is a degenerative disease, and whether that client has stabilized or is in remission

   2. That treatment is based on comprehensive evaluation, and that ongoing evaluation is part of the treatment and rehabilitation process

   3. Significant functional improvement in objective measurable terms when describing progress

   4. How client has applied progress from treatment sessions to other situations

8. The documentor must be sensitive to client rights, by:

   1. Avoiding personal or flippant remarks

   2. Including signed documentation about consultation with client, caregiver, and/or legally responsible person

   3. Obtaining signed and dated releases of information forms in compliance with state policy whenever documents are released or information is disclosed

9. Clinical records must be treated as a legal document, by:

   1. Typing or using ink for permanence

   2. Signing all record entries with name and professional title of primary care person and all appropriate professionals

   3. Dating and initialing materials from other facilities before entering them into permanent record. Note: For legal purposes, records need to be thorough, accurate, and include all necessary signatures and release authorizations.

10. A procedure for record maintenance should be instituted, such as:

    1. Conducting a records review to ensure that records are complete, accurate, and maintained on proper schedule

    2. Developing troubleshooting techniques by:

       1. Predicting potential problems

       2. Planning response to remediate each problem

       3. Following up on each problem

    3. Developing checklist for completing each form (so that it is accurately completed the first time)

11. Clinical records must be kept in an organized and systematic fashion, by, for example,

    1. Keeping a chronological log on inside folder for easy reference. Log should list dates and services provided, name or initials of the provider of the service and other identifying information, such as client number (e.g., contact sheet)

    2. Safeguarding against loss (e.g., affix records to record jackets)

    3. Separating current from historical files and storing them appropriately (See IIIA, IIIB, IIIC, and IVC.)

    4. Indicating where and to whom reports are sent (e.g., appropriate cc notations on reports, and consistent notations on contact sheets).