Documentation & Record Management Flashcards
7 cards from real ASHA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Record Management flashcards as text
In electronic health records (EHR), an audit trail primarily serves to:
Answer: Track who accessed or modified a record and when
An audit trail logs user access and modifications to records, which is essential for security, compliance, and accountability.
When an SLP documents discharge from services, which element is MOST important to include to demonstrate continuity of care?
Answer: Summary of progress toward goals and recommendations for follow-up or home practice
A discharge summary should document progress made and provide recommendations to ensure continuity of care after services end.
Which documentation practice best protects an SLP from liability when a client refuses a recommended service?
Answer: Documenting that the client was informed of the recommendation and the risks of refusal, and obtaining a signed refusal form
Informed refusal documentation, including the client's signature, protects the clinician by demonstrating that proper counseling occurred.
A pediatric SLP must obtain consent before releasing records to a child's school under FERPA. Who holds the right to provide this consent?
Answer: The parent or legal guardian until the student reaches age 18
Under FERPA, parents hold educational record rights until the student turns 18, at which point the rights transfer to the student.
Which abbreviation is generally considered problematic and discouraged in clinical documentation due to risk of misinterpretation?
Answer: QD (every day)
QD (every day) appears on The Joint Commission's 'Do Not Use' abbreviations list because it is easily confused with QID (four times a day).
An SLP working in a hospital is asked to co-sign a student clinician's note. What does the co-signature legally indicate?
Answer: The supervisor reviewed the documentation and accepts clinical and legal responsibility for its content
A supervisor's co-signature indicates review and acceptance of both clinical and legal responsibility for the documented information.
Progress notes written in SOAP format stand for which four components?
Answer: Subjective, Objective, Assessment, Plan
SOAP notes consist of Subjective (patient-reported), Objective (measurable data), Assessment (clinician interpretation), and Plan (next steps).