This module covers documentation for speech-language pathology services in different health care settings.
Accurate documentation provides a comprehensive evaluation report that helps determine the services planned for the patient. The reports and notes improve communication and continuity of care across the professionals providing care to the patient. Lastly, documentation provides the support for the codes you will report and billing for the services you provide.
Utilization review is an analysis by the third party payer or government agency to determine the number and types of services that were provided. You may be called to testify about a patient years after you provided the service. Your written record is all you have to go by. Your records also have to prove that what you did matches what you charged for, should your billing be audited. Compliance means your codes have to match what you did and your documentation has to back up those charges.
Accurate documentation describes the care you provided. The acronym ACUTE can be used as a mnemonic—documentation should be accurate, code-able, understandable, timely, and error free. Someone who was not present during the appointment should be able to review the records and understand exactly what was and was not done.
A good proverb to remember is, "If it wasn't documented, it wasn't done." Documentation should be completed at the time of service or at the time of the non-face-to-face contact, such as a phone conversation with the referring physician. Any patient or payer expects you to be able to describe the visit or other interaction that you are billing. You must also sign and date every entry.
Here is an example of the types of notes you can make to document non-face-to-face contact. These notes reflect services related to dysphagia care for a child. You should write all contacts made in regard to the patient's care even when you did not get a response. The other contacts reported here reflect the child's progress as observed by others. This verifies the services you are providing for the payer.
Your documentation serves as your promise that everything written down is accurate. Documentation should highlight the skilled services you provide, your clinical judgment, and objective data.
The Joint Commission (formerly the Joint Commission for Accreditation of Health Care Organizations), which accredits many health care organizations, has a list of abbreviations that may not be used. These abbreviations have been placed on the list because they can easily be confused or misread, leading to possible medical errors.
Compliance is the term used to describe all the rules that are needed to ensure accurate billing is followed. For example, if you have billed for an evaluation, your documentation should be for an evaluation. If you are charging a code that has a time element (like assessment of aphasia which is a per hour code), then the documentation has to match that length of time. The procedure code has to match the patient's diagnostic code. In other words, what you did for the patient has to make sense given their diagnosis. You must also provide services that are appropriate for an SLP. Not, for example, gait training.
You may need a physician's order, though this depends on whether you are working in a facility or in a private practice, and on who you are billing for the service. For example, Medicare may not require a physician's order, per se, but you must have a physician certify the plan of care. The physician's order should list the diagnosis for which you are seeing the patient.
Outpatient settings are those where the patient comes to see you. The comprehensive outpatient rehabilitation facility and outpatient rehabilitation facility (or rehabilitation agency) are Medicare provider settings with specific conditions of participation, such as the services required to qualify for the designation.
On the other hand, inpatient settings are those where the patient is in the bed, either on a short-term basis (like in an acute care hospital), or on a long-term basis (like in a skilled nursing facility). Home health care blurs the line, but the patient is considered by payers like Medicare to be an inpatient even though the professional goes to see the patient.
The provider settings in the previous slide may establish the documentation requirements based on institutional policies and procedures. However, in cases such as Medicare, the Medicare administrative contractor and national guidelines will set the requirements. In institutions, such as hospitals, compliance officers assist in ensuring documentation meets local or national standards.
School settings require that you understand their paperwork, mainly the Individualized Educational Plan. However, you may also have to complete other documentation, like daily or weekly notes and updates. The state education agency or local education agency should have documentation guidelines.
The reports you learn to write in the university clinic serve as good teaching tools. You learn to include comprehensive information about the patient. However, in clinical settings after you graduate, you will have to learn how to extract just the critical and essential information, and how to summarize so it's easy for physicians, payers, and others to interpret. They will want to find the necessary information quickly, so you should be as succinct as possible while still describing all necessary elements of the evaluation or treatment.
The basic types of documentation in outpatient settings are the evaluation report, the treatment plan or plan of care with certification, progress notes, and discharge summary.
The evaluation report is completed after your first visit. In some settings, you may be able to evaluate a client over several sessions, but most payers will only authorize payment for one date for the evaluation. The report should include a brief history that explains any related medical problems and specifically why the patient/client is there to see you. Any standardized or informal testing completed should be described and the results stated.
The evaluation report should describe the standardized tests administered and the results of those tests. Of course, any informal observations of the patient's communication or swallowing behavior should be included if it assists you in establishing a diagnosis and writing a treatment plan.
Provide normative data or interpretive statements so the reader knows what the data means. Always describe the communication or related disorder in functional terms, as well as in professionals terms. Your recommendations will include what you plan to do for the patient and any other evaluations or services the client might need.
Again, documentation requires your signature and not a replica. You should date your encounter and, if desired, you can include the date you dictated the report.
Make your report easy for the reader. This report may be read by a family member, a physician, a payer, or another medical or school professional. Use headers to differentiate the components of your evaluation, provide summary statements that translate your SLP jargon, and do not give the reader extra stress while looking for essential information—what you did, what you found, and what you recommend.
The treatment plan may be called a care plan, plan of care, or plan of treatment. It clearly defines what problem(s) you are addressing, what you plan to do, and how long it should take. The essentials are identifying information, diagnosis or diagnoses, long-term treatment goals in functional terms, short-term goals in functional terms, type and amount of therapy services, and the signature, date and professional identity of the person establishing the plan.
Today, speech-language pathology goals should be written in functional terms. For example, for a dysphagia patient, you should write that the patient will improve laryngeal elevation during swallowing to protect the airway, rather than simply say that the patient will improve laryngeal elevation. There aren't too many people who will read the goals and have any idea why you are working to achieve such a goal.
More and more payers are looking for measurable goals. Your treatment goals should be expressed in terms that can be measured over time to demonstrate progress. Again, functional goals and improvement need to be stated clearly.
Here are examples of short-term goals and treatment objectives. The short-term goal is for the patient to improve laryngeal elevation during swallowing, while examples of treatment objectives can be that the dysphagia patient will complete the Mendelsohn maneuver with small sips of water on 90% of trials. An objective for a voice patient could be that the patient completes falsetto 100% of the time. You must explain why you are striving for the patient to achieve such goals.
A progress note reflects what was done in a specific session. The SOAP format is commonly used in health care settings for the progress note. That is, the note should include subjective, objective, assessment, and plan data.
An example of a SOAP note is:
S: Subjective statements. For example, "client reports completion of practice voice exercises."
O: Objective data about what happened in the therapy session—include measurable statements.
A: Your analysis of how the session went. Did the patient improve in functional terms? What worked?
P: Your plan. When is the next visit? What will be addressed? What should the patient practice in the meantime?
The discharge summary is your succinct description of what occurred during treatment. It clearly states the progress made on each goal and any recommendations for further intervention. This discharge summary should be shared with the referral source and others involved in the care of the patient.
When you are providing services to a hospital inpatient the evaluation report may be a hand-written note in the patient's chart while the plan of care may be required to be entered on a specific form, such as the CMS 700. The link will provide a copy of CMS 700 form for PLAN OF TREATMENT FOR OUTPATIENT REHABILITATION. Though this form is no longer required by Medicare, many facilities still use it as a template.
Some settings need the start and end time of sessions recorded. This is related to how services are reimbursed in those settings. Skilled nursing facilities (or SNFs) are reimbursed based on the minutes of the services provided for Medicare Part A (usually within the first 100 days of Medicare coverage).
Depending on the setting, you may have to write a note each time the patient is seen or only weekly. If the note is written only weekly, you'll still have to document the other dates and times you saw the patient. There are specific rules for Medicare SNF progress notes (for instance, for Part B every 10 sessions or every 30 days, whichever is more frequent). Your employer will describe the requirements in detail.
Computerized documentation is becoming more commonplace. Examples are computerized charting that is designed with drop down menus where the speech-language pathologist can select options. On the other hand, outpatient settings may have software to standardize documentation with templates and spaces for information to be inserted.
When you're about to sign your name to any form of documentation, from evaluation to discharge summary, you should ask yourself these questions:
In summary, documentation must be accurate, complete, and timely. You can think of documentation as a reflection of you and your speech-language pathology services. ASHA provides current information on documentation in health care settings at the link provided on this slide. It includes Adult SLP Assessment Templates, Electronic Medical Records, Overview of Documentation for Medicare Outpatient Therapy Services, Documentation Guidelines for Medicare, Medical Record Retention, and Clinical Record Keeping in Speech-Language Pathology for Health Care and Third Party Payers.
At this time please proceed to Module Four, which covers documentation of audiology services, or Module Five, which covers coding, documentation, and additional reimbursement reporting requirements for speech-language pathology.