ASHA Documentation & Record Management 3 — Questions and Answers
Question 1: In electronic health records (EHR), an audit trail primarily serves to:
- Automatically correct documentation errors
- Track who accessed or modified a record and when (Correct answer)
- Generate billing codes from clinical notes
- Encrypt patient data for transmission
Correct answer: Track who accessed or modified a record and when
An audit trail logs user access and modifications to records, which is essential for security, compliance, and accountability.
Question 2: When an SLP documents discharge from services, which element is MOST important to include to demonstrate continuity of care?
- List of all standardized tests administered during the entire episode of care
- Summary of progress toward goals and recommendations for follow-up or home practice (Correct answer)
- Billing codes used throughout treatment
- Clinician's personal notes about the therapeutic relationship
Correct answer: Summary of progress toward goals and recommendations for follow-up or home practice
A discharge summary should document progress made and provide recommendations to ensure continuity of care after services end.
Question 3: Which documentation practice best protects an SLP from liability when a client refuses a recommended service?
- Documenting that the client was informed of the recommendation and the risks of refusal, and obtaining a signed refusal form (Correct answer)
- Simply removing the recommendation from the plan of care
- Noting the refusal only in a personal file, not the official record
- Discharging the client immediately from services
Correct answer: Documenting that the client was informed of the recommendation and the risks of refusal, and obtaining a signed refusal form
Informed refusal documentation, including the client's signature, protects the clinician by demonstrating that proper counseling occurred.
Question 4: A pediatric SLP must obtain consent before releasing records to a child's school under FERPA. Who holds the right to provide this consent?
- The child if over age 10
- The treating SLP
- The parent or legal guardian until the student reaches age 18 (Correct answer)
- The school principal
Correct answer: The parent or legal guardian until the student reaches age 18
Under FERPA, parents hold educational record rights until the student turns 18, at which point the rights transfer to the student.
Question 5: Which abbreviation is generally considered problematic and discouraged in clinical documentation due to risk of misinterpretation?
- Pt (patient)
- Dx (diagnosis)
- QD (every day) (Correct answer)
- Hx (history)
Correct answer: QD (every day)
QD (every day) appears on The Joint Commission's 'Do Not Use' abbreviations list because it is easily confused with QID (four times a day).
Question 6: An SLP working in a hospital is asked to co-sign a student clinician's note. What does the co-signature legally indicate?
- The supervisor observed every minute of the session
- The supervisor reviewed the documentation and accepts clinical and legal responsibility for its content (Correct answer)
- The student is now independently licensed
- The note was reviewed only for formatting errors
Correct answer: The supervisor reviewed the documentation and accepts clinical and legal responsibility for its content
A supervisor's co-signature indicates review and acceptance of both clinical and legal responsibility for the documented information.
Question 7: Progress notes written in SOAP format stand for which four components?
- Summary, Objectives, Assessment, Plan
- Subjective, Objective, Assessment, Plan (Correct answer)
- Status, Outcomes, Actions, Progress
- Symptom, Observation, Analysis, Prognosis
Correct answer: Subjective, Objective, Assessment, Plan
SOAP notes consist of Subjective (patient-reported), Objective (measurable data), Assessment (clinician interpretation), and Plan (next steps).
ASHA Documentation & Record Management 3
In electronic health records (EHR), an audit trail primarily serves to: