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
A third-party payer requests records to conduct a utilization review. The SLP must release the records because:
Answer: The client signed an Authorization for Release at the start of care that covers treatment, payment, and operations (TPO)
Under HIPAA, disclosure for payment purposes falls under Treatment, Payment, and Operations (TPO), which patients authorize at the start of care.
Which benchmark is typically used to determine whether documentation supports 'skilled' SLP services vs. a maintenance program?
Answer: Whether the service requires the clinical judgment and expertise of an SLP and cannot be safely or effectively performed by an unskilled person
Medicare and most payers define 'skilled' services as those requiring the expertise of a licensed clinician and that cannot be safely delegated to an unskilled caregiver.
A clinician accidentally sends a client's session notes to the wrong fax number. Under HIPAA, this is classified as a:
Answer: Potential breach requiring a risk assessment
A misdirected fax is a potential breach that triggers HIPAA's breach risk assessment process to determine whether notification is required.
The primary purpose of goal banking in SLP documentation systems is to:
Answer: Reduce the time needed to write individualized goals by providing pre-written, evidence-based goal templates that can be customized
Goal banking provides a library of evidence-based goal templates that clinicians can customize, improving efficiency while maintaining individualization.
Which law primarily governs the confidentiality of records for clients receiving substance abuse treatment in conjunction with communication disorders?
Answer: 42 CFR Part 2
42 CFR Part 2 provides stricter confidentiality protections for substance use disorder records than HIPAA, and applies when those records are part of a federally assisted program.
When documenting a dysphagia evaluation, a standardized diet texture level classification system that SLPs are encouraged to reference is:
Answer: The International Dysphagia Diet Standardisation Initiative (IDDSI) framework
IDDSI provides a universally recognized framework of 8 levels for classifying food textures and liquid thickness, supporting clear and consistent dysphagia documentation.
An SLP is closing a private practice. What is the MOST important documentation obligation before closing?
Answer: Notifying clients, ensuring records are stored for the legally required retention period, and arranging for client access to their records
Ethical and legal obligations require notifying clients of the closure, maintaining records for the mandated retention period, and ensuring clients can access their records.