Documentation in Health Care

Documentation is a critical vehicle for conveying essential clinical information about each patient’s diagnosis, treatment, and outcomes and for communication between clinicians, other providers, and payers. Documentation should proactively answer questions that payers ask about services, such as the following:

  • Is the service medically necessary?
  • Is it a service requiring the knowledge and skills of a speech-language pathologist?
  • Are the goals and treatment functionally relevant?
  • How does this service add value to the patient’s interdisciplinary care and overall health?
  • Does the documentation clearly support a specific and effective treatment for the patient’s condition?

ASHA does not dictate a single format or time frame for documentation because of the diversity of settings and payers. State or federal agencies governing health care or licensure for speech-language pathologists (SLPs) may have specific requirements. If state or federal requirements are more stringent than those of facilities, payers, and employment contractors, SLPs follow the state or federal requirements.

Unclear, vague, or absent documentation can result in denials by payers and make it difficult for the reviewer to follow the clinical judgment underlying a diagnosis and/or treatment. Other areas of knowledge necessary for documentation include coding and billing, requirements of the federal Health Insurance Portability and Accountability Act of 1996, and other key issues addressed below.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.

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