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
Under HIPAA, a covered entity must respond to a patient's request for access to their health records within how many days?
Answer: 30 days
HIPAA requires covered entities to act on a request for access to health records within 30 days, with one 30-day extension allowed.
Which term describes a written entry added to a clinical record after the original session note to correct or clarify information?
Answer: Addendum
An addendum is added after the fact to clarify or supplement existing documentation without altering the original note.
A speech-language pathologist is documenting a fluency disorder evaluation. Which component is MOST critical for justifying the need for skilled SLP services?
Answer: Functional impact of the disorder on daily communication
Medical necessity documentation must demonstrate how the disorder functionally impacts the patient's daily life to justify skilled services.
When an SLP documents a 'no-show' appointment, which element is LEAST necessary to include?
Answer: Specific therapy goals that would have been addressed
Specific therapy goals planned for a missed session are not required in a no-show note; documenting the missed appointment, contact attempt, and attendance pattern is sufficient.
Which standard specifies the minimum length of time that adult patient records must be retained in most U.S. states?
Answer: Retention laws vary by state but commonly range from 5 to 10 years
Record retention requirements vary by state, though most mandate at least 5–10 years after the last patient contact for adults.
A clinician wants to share a de-identified case study at a professional conference. Under HIPAA's Safe Harbor method, how many specific identifiers must be removed?
Answer: 18
HIPAA's Safe Harbor method requires removal of 18 specific identifiers before health information is considered de-identified.
Which type of goal documentation format is MOST aligned with evidence-based and measurable outcomes required by third-party payers?
Answer: SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound)
SMART goals provide the specificity and measurability that payers and accreditors require to assess progress and medical necessity.