ASHA Documentation & Record Management 2

Question 1

Under HIPAA, a covered entity must respond to a patient's request for access to their health records within how many days?

Accepted Answer

30 days

Answer

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?

Accepted Answer

Addendum

Answer

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?

Accepted Answer

Functional impact of the disorder on daily communication

Answer

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?

Accepted Answer

Specific therapy goals that would have been addressed

Answer

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?

Accepted Answer

Retention laws vary by state but commonly range from 5 to 10 years

Answer

Record retention requirements vary by state, though most mandate at least 5–10 years after the last patient contact for adults.

(ASHA) American Speech-Language-Hearing Association Certification Practice Test

(ASHA) American Speech-Language-Hearing Association Certification Practice Test

ASHA Documentation & Record Management 2