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Documentation in Health Care

Documentation is a critical vehicle for conveying essential clinical information about each patient's diagnosis, treatment, and outcomes and for communication between clinicians and payers. Clinicians must efficiently respond to the questions that payers are asking about each service:

  • Is it medically necessary?
  • Is it a service requiring the knowledge and skills of a speech-language pathologist?
  • Are the goals and treatment functionally relevant?
  • How does this service add value to the patient's interdisciplinary care and overall health?

Because of the diversity of settings and payers, ASHA does not dictate a single format or timeframe for documentation. State or federal agencies governing health care or licensure for speech-language pathologists may have specific requirements; if those requirements are more stringent, they supersede requirements of facilities, payers, and employment contractors.

As the saying goes, "If you didn't document it, you didn't do it." Unclear, vague, or absent documentation can result in denials by payers and make it difficult for the reader to follow the clinical judgment underlying the diagnosis and treatment. Other areas of knowledge necessary for documentation include coding and billing, requirements of the federal Health Insurance Portability and Accountability Act (HIPAA), and other key issues addressed below.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.