The scope of this page includes documentation of audiology services across settings and populations as well as basic information on coding, billing, and reimbursement for audiology services.
Documentation is a critical vehicle for conveying essential clinical information about each client/patient's diagnosis, plan of care, intervention, and outcomes. It serves to detail communication between clinicians for care coordination and transfer of care and also between clinicians and payers. Any type of documentation to be shared with clients/patients or family members/caregivers should be readable, understandable, and written in plain language. See Health Literacy.
ASHA does not dictate a single format or timeframe for documentation. State or federal agencies governing health care, education, or licensure for audiologists may have specific documentation requirements; if those requirements are more stringent, they supersede requirements of facilities, payers, and employment contractors.
Unclear, vague, or absent documentation can result in negative consequences such as inappropriate or inadequate intervention or referral, reduced continuity of care, denials by payers, and misrepresentation of the clinical judgment underlying the given diagnosis and intervention.