ASHA Documentation & Record Management 2 — Questions and Answers
Question 1: Under HIPAA, a covered entity must respond to a patient's request for access to their health records within how many days?
- 15 days
- 30 days (Correct answer)
- 60 days
- 90 days
Correct 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.
Question 2: Which term describes a written entry added to a clinical record after the original session note to correct or clarify information?
- Addendum (Correct answer)
- Amendment
- Errata
- Revision
Correct answer: Addendum
An addendum is added after the fact to clarify or supplement existing documentation without altering the original note.
Question 3: A speech-language pathologist is documenting a fluency disorder evaluation. Which component is MOST critical for justifying the need for skilled SLP services?
- Client's educational history
- Functional impact of the disorder on daily communication (Correct answer)
- Family's preferred therapy schedule
- Clinician's years of experience
Correct 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.
Question 4: When an SLP documents a 'no-show' appointment, which element is LEAST necessary to include?
- Date and time of the missed appointment
- Attempt to contact the client
- Specific therapy goals that would have been addressed (Correct answer)
- Standing of the client's attendance pattern
Correct 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.
Question 5: Which standard specifies the minimum length of time that adult patient records must be retained in most U.S. states?
- 3 years after last contact
- 5 years after last contact
- 7 years after last contact
- Retention laws vary by state but commonly range from 5 to 10 years (Correct answer)
Correct 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.
Question 6: 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?
- 12
- 15
- 18 (Correct answer)
- 21
Correct answer: 18
HIPAA's Safe Harbor method requires removal of 18 specific identifiers before health information is considered de-identified.
Question 7: Which type of goal documentation format is MOST aligned with evidence-based and measurable outcomes required by third-party payers?
- Narrative paragraph goals
- SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) (Correct answer)
- Broad developmental milestone goals
- Open-ended process goals
Correct 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.
ASHA Documentation & Record Management 2
Under HIPAA, a covered entity must respond to a patient's request for access to their health records within how many days?