Documentation in Health Care Settings

Documentation Tips

• No "universal template" or documentation style exists—specific documentation requirements or formats may vary by institution or payer.
• Remember, "If you didn't document it, it didn't happen."

For answers to frequently asked questions, read ASHA's Documentation: FAQs.

Related Resources

• Adult SLP Assessment Templates
• Electronic Medical Records
• Overview of Documentation for Medicare Outpatient Therapy Services
• Documentation Guidelines for Medicare [PDF]
• Medical Record Retention
• Common Medical Abbreviations [PDF]
• HIPAA Information
  

Select Articles from The ASHA Leader

• Managing Medicare: Documenting What You Do Is As Important As Doing It
• Documentation for Private Health Plans
• Responding to the Dysphagia Consult: A Report Writing Primer
• Clinical Documentation in Speech-Language Pathology: Essential Information for Successful Practice
• Paper, Paper, Everywhere? How to go Paperless in Your Private Practice