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Documentation That Works

Emory Voice Center, Emory University
Atlanta, GA

Clinical documentation allows the speech-language pathologist to chart the events, findings, and clinical impressions gleamed from the patient encounter. Good record keeping enhances clinical follow through with the transfer of information from evaluation findings to therapeutic invention or from session to session to ensure the progression of therapy. Poor record keeping poses a threat to evaluation and therapy follow-through, to insurance reimbursement, and to the development of a clinical record that meets legal standards. The purpose of this article is to provide a streamlined reference for those documenting voice evaluations and therapy encounters. Clinical documentation meeting the guidelines proposed by ASHA (1994, 2006, 2007a), and with regard to Medicare requirements for the documentation of evaluation, plan of care, treatment note, progress note, and discharge note is presented. The use of templates to reduce documentation load is discussed as is the advent of electronic medical record. Documentation can be overwhelming and the amount of information required in documentation of a single therapy session seems to increase each year. Assuring that documents meet medical/legal guidelines and individual payer guidelines is paramount. ASHA resources for assisting clinicians in the development of documentation are highlighted in the article.