Documentation of Audiology Services

The scope of this page includes documentation of audiology services across settings and populations as well as basic information on coding, billing, and payment for audiology services. For information specific to documentation in educational settings, see the ASHA Practice Portal page on Documentation in Schools.

Documentation is critical in conveying essential clinical information about each client or patient and their evaluation, diagnosis, plan of care, intervention, and outcomes. It allows for accurate communication among clinicians during care coordination and transfer of care as well as between clinicians and payers. Any type of documentation to be shared with clients/patients or family members/care partners should be readable, understandable, and written in plain language. See ASHA’s resource on health literacy.

ASHA does not dictate a single format or time frame for documentation. State or federal agencies governing health care, education, or licensure for audiologists may have specific documentation requirements. If those requirements are more stringent, they supersede the requirements of facilities, payers, and employers.

Unclear, vague, or absent documentation can result in negative consequences such as missed provider referrals, inadequate intervention, reduced continuity of care, denials by payers, and misrepresentation of the clinical judgment underlying the given diagnosis and intervention. See the ASHA Code of Ethics (ASHA, 2023).

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.

ASHA Corporate Partners