Accurate, efficient, quantitative, and qualitative documentation of clinical services is an important part of the role of the speech-language pathologist in any medical or clinical setting. Documentation is used to justify services to third party payers, demonstrate compliance with various regulatory requirements, function as an official source of information in a legal proceeding, and communicate to referral sources clinical findings and client progress. This program defines critical variables that describe “medical necessity” and “skilled service of speech-language pathology” in order to get claims paid. A brief overview of ASHA documentation templates, which provide structure and guidance across a variety of settings for adolescent and adult clients, is provided, along with a discussion of the various types of documentation systems. Suggestions for goal-writing formats are also a focus, as is the use of documentation to measure clinical outcomes.

Learning Outcomes
You will be able to:

• define “medical necessity” of speech-language pathology services to meet payer requirements
• document the need for “skilled” speech-language pathology services and improve clinical operational performance
• write goals that reflect the “skilled” nature of the service provided
• write statements that reflect the change in functional status achieved as a result of the service
• describe and evaluate the efficiency of three types of documentation systems: computer-based, handwritten and dictation/transcription

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