ASHA Documentation & Record Management 3

Question 1

In electronic health records (EHR), an audit trail primarily serves to:

Accepted Answer

Track who accessed or modified a record and when

Answer

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?

Accepted Answer

Summary of progress toward goals and recommendations for follow-up or home practice

Answer

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?

Accepted Answer

Documenting that the client was informed of the recommendation and the risks of refusal, and obtaining a signed refusal form

Answer

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?

Accepted Answer

The parent or legal guardian until the student reaches age 18

Answer

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?

Accepted Answer

QD (every day)

Answer

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).

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