Documentation is a critical vehicle of communication among clinicians, payers (i.e., Medicaid), administrators, and other stakeholders in a student's education and well-being. It should provide clinical information about a student's diagnosis, treatment, and outcomes, and efficiently answer the questions that clinicians, administrators, payers, and/or stakeholders may ask, including those presented below:
- Is the service educationally and/or functionally relevant?
- Does a service require the knowledge and skills of an audiologist and/or speech-language pathologist?
- How does this service add value to the student's education, interdisciplinary care, and/or overall health?
Documentation formats vary among education systems, and ASHA does not dictate a single format or timeframe. State or federal agencies governing schools, Medicaid reimbursement, or audiology and speech-language pathology regulations may have specific requirements for documentation. Any documentation must meet state and federal agency requirements. School districts, payers, or employment contractors may have additional requirements. See ASHA State by State for more information.
Strong documentation is critical for making sound decisions for students. As the saying goes, "If you didn't document it, you didn't do it." Unclear, vague, or missing documentation can result in compliance violations, ethical charges, inability to defend decisions in a due process situation, difficulty following the clinical judgment underlying the diagnosis and treatment, and denials for Medicaid reimbursement. Any official student record can be subpoenaed. Strong documentation must be provided for diagnostic, treatment, progress reporting, and consultative services.