Documentation & Record Management Flashcards

Under ASHA's Code of Ethics, an SLP who discovers a billing error in past records is ethically obligated to:

Answer: Correct the record and report the error to the appropriate party

ASHA's Code of Ethics requires honesty and integrity, including correcting and disclosing billing or documentation errors when discovered.

Which scenario represents an appropriate use of a late entry in clinical documentation?

Answer: Adding documentation for a session that occurred 2 days ago that was inadvertently omitted

A late entry is appropriate when a legitimate session was inadvertently not documented; it should be clearly labeled with the current date and reason for delay.

Which document outlines the specific services, frequency, duration, and goals for a client receiving SLP services in a school setting?

Answer: Individualized Education Program (IEP)

The IEP is the legally binding document in school settings that specifies the services, frequency, goals, and accommodations for eligible students.

In value-based care models, SLP documentation is increasingly expected to include evidence of:

Answer: Functional outcomes and quality-of-life improvements

Value-based care ties reimbursement to functional outcomes and patient-centered quality improvements rather than volume of services.

A client requests that an inaccuracy in their medical record be corrected. Under HIPAA, the covered entity may deny the amendment request if:

Answer: The record was not created by the covered entity

HIPAA allows denial of an amendment request when the record in question was not created by the entity receiving the request.

Which element differentiates a plan of care from a session note in SLP documentation?

Answer: The plan of care establishes the overarching treatment approach, goals, and projected timeline before or at the start of services

A plan of care is a prospective, overarching document establishing goals and approach, whereas session notes record what occurred during individual treatment visits.

When using telehealth for SLP services, documentation should additionally include:

Answer: The platform used, client's location at time of service, and confirmation that the technology was appropriate for the service rendered

Telehealth documentation must capture the delivery platform, client location (for licensure and billing purposes), and technology adequacy to meet payer and regulatory requirements.