Documentation in Health Care (2024)

Documentation Principles in Health Care Settings

Documentation plays a critical role in communicating the need for evaluation and treatment services (medical necessity) to payers and justifying why those services require the skill of the SLP. Documentation requirements vary by practice setting and by payer. Medicare outpatient therapy documentation guidelines serve as the standard for many other insurance plans. Documentation principles should also be followed to accurately document the provision of elective services that may not be deemed “medically necessary” (e.g., accent modification).

Documentation follows a plan of care (POC) that is established after clinical assessment. However, this POC is subject to modification as the patient progresses in therapy.

Documentation is read by clinicians as well as claims reviewers from varying backgrounds and experiences; it is important that notes and reports are clear and legible and that they efficiently convey all the essential information that is needed for clinical management and reimbursem*nt.

Medical Necessity

Demonstrating medical necessity is an essential element of justifying reimbursem*nt for SLP services. Medical necessity is defined by the payer for a service (e.g., Medicare). Medicare defines medical necessity by exclusion, stating that “…services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member are not covered…” (Centers for Medicare & Medicaid Services [CMS], 2014r-a).

Medicare further itemizes circ*mstances for reasonable and necessary services in local coverage determinations as “safe and effective, not experimental or investigational…, appropriate in accordance with accepted standards of medical practice…, furnished in a setting appropriate to the patient’s medical needs and condition; …ordered and furnished by qualified personnel…” (CMS, 2014r-b). Medicare stipulates that “…the services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist…” (CMS, 2014r-c). Please see ASHA’s resource on introduction to Medicare for further information.

Providing justification for medical necessity as well as reasonable and necessary care requires addressing the following elements. Services should be

reasonable—provided with appropriate

amount—number of times in a day the type of treatment will be provided,
frequency—number of times in a week the type of treatment is provided,
duration—number of weeks or total treatment sessions, and
accepted standards of practice (please see Scope of Practice in Speech-Language Pathology);

necessary—appropriate treatment for the patient’s medical and treatment diagnoses and prior level of function;
specific—targeted to a particular treatment goal;
effective—expectation for functional improvement within a reasonable time or maintenance of function in the case of degenerative conditions, where the patient’s prior level of function serves as the baseline; and
skilled—requires the knowledge, skills, and judgment of an SLP rather than a less skilled caregiver.

Relevant documentation for establishing medical necessity may include (ASHA, 2004)

a medical/behavioral history—pertinent medical history including relevant prior treatment that influences the speech-language treatment. This history includes a concise description of the functional status of the patient prior to the onset of the condition that requires the services of an SLP;
speech, language, swallowing, and sensory (e.g., hearing and vision) impairments as well as related disorders—the diagnosis established by the SLP (e.g., aphasia or dysarthria);
the date of onset of the deficit(s);
a physician referral/order, as indicated by the payer;
an initial evaluation and date;
the evaluation procedures used by the SLP to diagnose speech, language, swallowing, and related disorders;
an individualized POC and the date it is established;
daily notes/progress notes (frequency depending on payer and facility policies);
documentation of progress made towards goals, including description of the complexity of skills targeted; and
updated patient status reports concerning the patient’s current functional communication and/or swallowing abilities/limitations.

Skilled Services

Medicare (and other plans that adopt Medicare documentation guidelines) stipulates that services eligible for reimbursem*nt must be at a level of complexity and sophistication that requires the specific expertise and clinical judgment of the qualified health care professional, thus meeting the definition of skilled services. Level and complexity may refer to the patient’s condition requiring the skills of an SLP or to the level and complexity of the services provided.

SLPs use their expert knowledge and clinical reasoning to perform the skilled services listed below and document them appropriately.

Analyze medical/behavioral/clinical data collected to select appropriate evaluation tools to determine diagnosis, prognosis, and need for therapy.

Design a POC that includes short- and long-term measurable and functional goals, the anticipated length of treatment, discharge criteria, frequency and duration, and a home exercise program if applicable. Train patients and/or family in the use of compensatory skills and strategies, as appropriate.

Develop/deliver treatment techniques, activities, and strategies that follow a hierarchy of complexity to achieve the target skills for a functional goal.

Modify the complexity of tasks, level of cueing or assistance provided, or goal criteria based on performance. Conduct an ongoing assessment of performance, motivation, participation, and goal progress and modify the treatment plan as needed. Adjust augmentative and alternative communication (AAC) systems as needed. Determine when discharge from treatment is appropriate. Evaluate the current functional performance of patients with chronic or progressive conditions and provide treatment to optimize current functional ability, prevent deterioration, and establish and/or modify maintenance programs.

Engage and educate patients and caregivers. Confirm patient/caregiver participation and understanding of the diagnosis, treatment plan, strategies, precautions, and activities through “teach back” and/or return demonstration. Provide positive reinforcement, expectation of results, and/or practice of skills for generalization outside the therapy setting.

Billing and Insurance

As payment models evolve away from fee-for-service to bundled care and efficiency, SLPs in health care may increasingly have to justify the value of their contribution to the coordinated care of the interdisciplinary team and to the patient’s functional outcomes, emphasizing the quality and safety of services over the quantity of services. SLPs consider if the services

Medicare

Medicare documentation guidelines (see, e.g., Overview of Documentation for Medicare Outpatient Therapy Services) may serve as minimum standards adopted by other payers. Documentation components required by Medicare include

an evaluation;
a POC (also called a treatment plan), including
- diagnoses;
- long-term treatment goals; and
- the type (e.g., group, individual), amount, duration, and frequency of therapy services;
treatment notes;
progress reports; and
a discharge summary.

Medicaid

Medicaid is a joint federal- and state-funded program to assist states in providing medical care to low-income individuals and those who are categorized as medically needy. Each state Medicaid program dictates documentation requirements for providers. State-specific guidelines can be found in the state’s Medicaid plan and/or Medicaid guidance documents (e.g., the state provider handbook). For more information, go to ASHA’s web page, Medicaid toolkit.

Private Insurance

Private payers do not follow a universal documentation template. SLPs are responsible for identifying the requirements of each payer; however, Medicare documentation requirements may be useful as basic guidelines. Documentation typically reports why the patient was seen, what assessment or treatment was provided, clinical findings (e.g., diagnoses), and what (if any) treatment was recommended and provided in a way that justifies the assigned diagnosis and procedure codes (see Coding for Reimbursem*nt). Health plans reviewing claims require documentation to justify the services delivered.

Components of Documentation

Documentation must

be signed and dated;
include the credentials of the clinician providing services;
indicate if someone other than the clinician was involved in developing/implementing the POC (e.g., graduate student, assistant); and
indicate if an interpreter was present, if applicable.

Documentation of clinical interactions should present the events of a session and patient/client interactions, the type of therapy (e.g., group/individual/co-treatment), the location of therapy (e.g., in person or via telepractice), and any accommodations and modifications to clinical procedures. Relevant modifiers and place-of-service codes should be used when coding/billing. For telepractice considerations, please see Payment and Coverage of Telepractice Services: Considerations for Audiologists and Speech-Language Pathologists and ASHA’s Practice Portal page on Telepractice.

ASHA’s Preferred Practice Patterns for the Profession of Speech-Language Pathology may provide guidance. Clinicians must also meet the documentation requirements of the facility and payer.

Clinical records are legal documents, and the signatures of those entering information should reflect their roles within the organization. The official title of the clinician endorsed by ASHA is speech-language pathologist, which may be different from the title assigned by the employer. All relevant professional credentials need to be represented in documentation (i.e., someone who holds the ASHA Certificate of Clinical Competence may write “CCC-SLP”). Facility rules may also specify the need to include information about licensure or additional credentials. SLPs holding an advanced degree in another field, such as psychology or business, should specify their credentials appropriately. See Use of Graduate Doctoral Degrees by Members and Certificate Holders. Members holding specialty certification should also include those credentials.

All student documentation should be cosigned by a qualified provider, as defined by the payer and/or state licensure board guidelines.

If Clinical Fellows (CFs) are granted provisional licensure in the state, then they do not need to have their documentation cosigned. In states that do not have provisional licensure for CFs, Medicare views them as students and requires 100% supervision by a licensed SLP. In these instances, the supervising SLP would have to sign all notes as the qualified provider.

Components of Documentation for Speech-Language Pathology Assistants (SLPAs)

SLPAs may document student, patient, or client performance (e.g., collecting data; preparing charts, records, and graphs) and report this information to their supervising SLP in a timely manner. However, SLPAs do not sign or initial formal documents (e.g., POCs, reimbursem*nt forms, reports) without the supervising SLP’s co-signature. The payer, state and/or facility, or program may be involved in decisions about the extent to which SLPAs can provide and document clinical services and if they can be reimbursed for these services. There may be geographical variation in reimbursem*nt for SLPA services. Please see Scope of Practice for the Speech-Language Pathology Assistant (SLPA) for further information.

Types of Documentation

The content of clinical documentation differs depending on the context (e.g., an evaluation report contains information different from a treatment note). However, some items may be consistently addressed across documentation types. Examples of these include

potential barriers and/or facilitators to progress (see Social Determinants of Health);
session length and/or start and stop times, as required;
the location of service (i.e., in person, via telehealth, or both); and
the service delivery model employed (e.g., group, individual).

Evaluation Report

The evaluation report is typically a summary of the evaluation process, any resulting diagnoses, and a plan for service. The evaluation report may include the following elements:

reasons for referral
case history, including prior level of function, medical complexities, previous and current history of speech therapy, and comorbidities
review of auditory, visual, motor, and cognitive status
standardized and/or nonstandardized methods of evaluation
primary and SLP diagnoses
analysis and integration of information to develop prognosis, including outcome measures and projected outcomes (see ASHA’s National Outcomes Measurement System [NOMS])
prognostic predictors
recommendations
referrals to other professionals as needed
POC
- treatment amount, frequency, and duration
- long- and short-term functional goals (see the International Classification of Functioning, Disability and Health [ICF] framework)

Please see ASHA’s Practice Portal resource templates and tools for materials to assist with evaluation.

Treatment Note

A treatment note is a record of a treatment session and includes information regarding the treatment session. For any timed codes utilized, the treatment note should document the total treatment time to support the number of units and codes billed for each treatment day. The SOAP (subjective, objective, assessment, plan) format is commonly used in health care settings to demonstrate the skilled services provided and the need for ongoing services. SOAP notes include the following:

Subjective statements
- For example, “Client reports completion of practice voice exercises”
Objective data about what happened in the therapy session. Objective data include both patient performance and what the SLP did as a result (i.e., skilled intervention), as well as
- measurable statements and
- the level of assistance/cueing or other methods of intervention provided during the session.
Analysis of how the session went
- Did the patient improve in functional terms?
- What worked?
Plan
- When is the next visit?
- What will be addressed?
- What should the patient practice in the meantime?

SOAP notes and all treatment notes typically include

patient response;
the service delivery model employed (e.g., group/individual/telepractice);
the use of an interpreter, if indicated;
subjective and objective data on progress toward functional goals with comparison to prior sessions; and
skilled services provided (e.g., materials and strategies, patient/family education, analysis and assessment of patient performance, modification for progression of treatment).

Progress Note

Progress notes are written at intervals that may be stipulated by the payer or the facility and report progress on long- and short-term goals. A progress note may also follow the SOAP note format mentioned in the Treatment Note section above. Progress notes for Medicare must be written at or before every 10th session and typically include

the number of sessions, the location, and attendance;
skilled services provided (see the Skilled Services section above);
objective measures of progress toward functional goals;
a justification for the ongoing treatment in the context of medical necessity; and
changes to the goals or POC, as appropriate.

Discharge Summary

Discharge summary notes are prepared at the conclusion of treatment and typically include

dates of treatment,
goals and progress toward goals,
the treatment provided,
objective measures (e.g., pre- and posttreatment evaluation results, outcome measures),
functional status (see the link for the ICF framework above),
patient/caregiver education provided,
the reason for discharge, and
recommendations for follow-up.

Documenting Communications

Communication with parents/caregivers and stakeholders (e.g., telephone calls) may be documented. Options for the form of documentation used include

electronic or paper files or
recorded files (e.g., audio files recorded by a web conferencing program) that can be included in the patient’s electronic record or transcribed.

Please note the following best practices:

For each record, include the time and date (including the year) and identify participants.
For recorded conversations, make sure all participants are aware that the conversation is being recorded and provide documented consent. In many states, permission to record a conversation is legally required. If you are unsure about your state’s stance, either obtain permission from all parties prior to recording the conversation or research the matter in advance of the call, conversation, or meeting.

Documentation Formats

ASHA does not prescribe a specific format for documenting, either in paper-based records or electronically. However, ASHA does provide resources for clinicians, including clinical assessment templates.

Documentation should include information required by payers in addition to relevant clinical information. Succinctness and legibility are critical factors, as they allow those reading the documentation to locate and read key information easily and quickly. Any acronyms or abbreviations used should be consistent with facility policy on accepted medical abbreviations.

Health care facilities and other health providers adopt electronic medical records to standardize the collection of patient data, improve coordination of care, and facilitate the reporting of quality measures.

Within medical facilities, SLPs should participate in the development of the templates that they will use for billing and clinical documentation. Templates developed by or adapted from other disciplines may lack the necessary specificity to describe the patient’s diagnosis and treatment. Documentation templates may feature the selection of prefilled criteria (e.g., drop-down menus, checklists) or allow entry of free-text. There are potential benefits and drawbacks for either method. For example, prefilled criteria may improve a clinician’s documentation efficiency but not allow a clinician to enter specific information. See Electronic Medical Records (EMR) and Practice Management Software for Speech-Language Pathologists.

Medicare requires the electronic submission of billing information if the practice employs more than 10 full-time employees.

Ethical Issues

The ASHA Code of Ethics, Principle 1, Rule Q, states “Individuals shall maintain timely records and accurately record and bill for services provided and products dispensed and shall not misrepresent services provided, products dispensed or research and scholarly activities conducted” (ASHA, 2018). Furthermore, Issues in Ethics: Misrepresentation of Services for Insurance Reimbursem*nt, Funding, or Private Payment prohibits misrepresenting coding or clinical information for the purposes of obtaining reimbursem*nt (ASHA, 2010).

The proper way to make changes to documentation is to either create a new entry with the information that has changed or draw a line through the incorrect information and sign and date the change without removing or obliterating what had been written. Any addendum should include the date the change is being entered into the record and the name and signature of the person making the change, as well as the reason for the change.

If a clinician is asked to change information because it is incorrect or incomplete (e.g., wrong date, wrong treatment goal, or forgot to note something of importance), then using the procedure described above should suffice. However, if there are other reasons for the change (e.g., correcting pronoun use), then the clinician needs to consider the legal and ethical implications before making any changes.

Clinicians should not misrepresent services or findings as this may constitute fraud and may violate the ASHA Code of Ethics and licensure laws. If a clinician has evidence that an administrator or other colleague has altered that clinician’s documentation to reflect incorrect information or without properly noting the changes, then the clinician should consider their ethical obligation to report the behavior and to protect their license and certification. Please see Compliance Reporting [PDF] for further information.

Legal Issues

The medical record is a legal document. Changes made to the medical record should be dated and initialed by the original documenter, not erased, deleted, or whited out. The patient or the individual’s personal representative (e.g., legal guardians of minors or any person with authority under state law to make health care decisions for the individual) has a right to review their medical records, as allowed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). They may also have a right to copies of the record; however, limitations on what they can have copied may exist, such as legal restrictions. Please see Personal Representatives for further details.

One such restriction is copyright law. Publishers of tests often have copyright restrictions regarding photocopying protocols. Such information may be available on the publisher’s website or obtained by contacting the publisher (e.g., Pearson) directly.

HIPAA

The purpose of HIPAA is to make it easier for people to keep health insurance, ensure the confidentiality and security of protected health information (PHI), and help the health care industry control administrative costs. Health care providers and other entities who conduct electronic transactions or handle PHI must comply with certain HIPAA regulations, such as rules surrounding patient privacy and PHI, the use of the National Provider Identifier, and the transition to the 10th revision of the ICD.

Medical Record Retention

Each state may have unique medical record retention laws. Such laws may vary by setting or type of record. In addition, federal law (e.g., HIPAA), payers, and regulatory or accrediting agencies may have regulations governing record retention. SLPs should know all applicable regulations and abide by the most stringent. State laws regarding record retention are passed by the state legislature and may be found on the state’s website or the Department of Health’s website. Hospital medical records staff should also be knowledgeable about applicable laws and regulations.

HIPAA regulations do not include medical record retention requirements. However, HIPAA rules do require the application of appropriate administrative, technical, and physical safeguards to protect the privacy of information for as long as records are maintained.

The Centers for Medicare & Medicaid Services (CMS) requires that patient records for Medicare beneficiaries be retained for a period of 5 years (see 42CFR482.24(b) [PDF]). Medicaid requirements may vary by state. Additional information about record retention rules [PDF] is available from CMS.

Ownership of documentation is situation specific and highly dependent upon state laws and contract language. For example, if the clinician is an employee, then the records likely belong to the employer. If the clinician is an independent contractor, ownership of the physical record will depend upon contract terms. In situations where the clinician is a partner in the business, ownership of business property may vary by state laws and contract terms.

Data collection methods used during the intervention session to assist in recording performance on goals are generally not considered part of the record. Check marks or other informal means of recording data during the treatment session assist the treating clinician with maintaining records and comparing performance across intervention sessions to determine the level of progress toward goals. The interpretation of those data is meaningful and considered part of the record. SLPs should maintain an ongoing record of data, as this information may be requested for a litigation proceeding and/or their performance evaluation.

ASHA does not have a policy on retention of video or digital images, such as videofluoroscopic swallowing studies. SLPs should consult their facility policy for guidance.

The Joint Commission

The Joint Commission released a revised set of standards on patient-centered communication in 2010. The standards outlined “effective communication, cultural competence, and patient- and family-centered care as important components of safe, quality care” (The Joint Commission, 2010). Documentation is important in order to demonstrate compliance with The Joint Commission requirements [PDF]. According to The Joint Commission (2010), information that should be documented includes

the patient’s communication needs, including preferred language, use of hearing aids, or the need for an AAC device or communication board;
the use of an interpreter;
cultural or religious beliefs that potentially influence service provision;
any changes or modifications to standardized testing tools (including translation); and
any accommodations made during treatment services to address the linguistic and cultural or religious beliefs of the patient.

For further information on the use of an interpreter, please see ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators.

ICF Framework for Documentation

The ICF is a classification of health and health-related domains and is a framework for measuring health and disability at both individual and population levels (WHO, 2001). The ICF also includes a list of environmental factors, as the functioning and disability of an individual occurs in a context. ASHA’s Preferred Practice Patterns for the Profession of Speech-Language Pathology were developed to be consistent with this framework.

Comprehensive assessment, intervention, and support address the following components within the ICF framework:

Body functions and structures: identify and optimize underlying anatomic and physiologic strengths and weaknesses related to communication and swallowing effectiveness. This includes mental functions, such as attention, as well as components of communication, such as articulatory proficiency, fluency, and syntax.
Activities and participation, including capacity (under ideal circ*mstances) and performance (in everyday environments): involves the practitioner performing the following services:
- assessing the communication- and swallowing-related demands of activities in the individual’s life (contextually based assessment);
- identifying and optimizing the individual’s ability to perform relevant/desired social, academic, and vocational activities despite possible ongoing communication and related impairments; and
- identifying and optimizing ways to facilitate social, academic, and vocational participation associated with the impairment.
Environmental and personal factors: identify factors that are barriers to or facilitators of successful communication (including the communication competencies and support behaviors of everyday people in the environment). Contextual factors are personal factors (e.g., age, race, gender, education, lifestyle, and coping skills) and environmental factors (e.g., physical, technological, social, and attitudinal).

For examples of functional goals, please see the ICF page on ASHA’s website.