GENERAL MODULE MEDICAL/CLINICAL RECORD
MANAGEMENT FOR SPEECH LANGUAGE PATHOLOGIST
(Developed
by Kunnampallil Gejo John, MASLP, Speech Language Pathologist)
INTRODUCTION
The clinical/medical record is
the most important practice tool used by Speech Language Pathologist/Therapist,
regardless of specialty, because it supports and enhances the care that our patients
receive. It is also a legal document that details the care you provide to your
patients, and acts as a record of your billing practices. In the event of a random
or specifically indicated review of a SLP’s medical or billing practice, the
medical record will come under scrutiny. The medical review committees of the
regulatory Colleges of Physicians /insurance team and the health ministry’s base
their decisions primarily on the medical record without interpretation by the Speech
Language Pathologist/Therapist.
As a Speech Language
Pathologist/Therapist, you deal with patient records every day. What percentage
of your written or electronic medical records would meet regulatory standards
as legible, comprehensive and stand-alone documents?
All Speech Language
Pathologist/Therapist have a vested interest in ensuring that their medical records
meet provincial licensing standards. Unfortunately, many medical training
programs still do not offer formal instruction on the best-practice standards
needed to maintain the structure, content and legal requirements of medical
records
WHY SPEECH LANGUAGE PATHOLOGIST/THERAPIST MUST MAINTAIN GOOD MEDICAL
RECORDS
There are five reasons to keep
comprehensive medical records for every patient.
First and foremost, a
comprehensive medical record enhances and supports the patient-centred care the
patient receives.
More specifically, we must
maintain good medical records:
·
To provide an accurate and complete account of
the history, examination, investigations, treatment plan and ongoing progress
of the patient;
·
To assist colleagues when they are consulted or
are assuming care for your patients;
·
To facilitate the preparation of chart summary,
insurance and medico-legal reports; and
·
To defend and protect the best interests of the
physician and patient in the event of a review by the provincial licensing body
or Ministry of Health billing review agency, and especially in the event of a
malpractice action.
As an account of the patient’s medical history: Considering the
number of patients you will deal with over an extended period of time, it is
essential that you take the time to ensure that your medical records are
comprehensive, accurate, legible and complete. This applies to all physicians,
whether you provide ongoing care for the patient or are brought in only for
periodic assessments and consultations. Relying on your memory is a formula for
disaster.
As a reference for colleagues: A comprehensive record with a clear,
well-organized history and workup assists colleagues who cover for your
occasional absences, or who see your patients in consultation. They will save
valuable time and healthcare resources if they can avoid redundant
investigations and medication trials. If you have clearly documented the next
medical management steps in the chart, you can also reduce the chance that
another physician will drastically change the treatment plan. Not only will you
save your colleagues time, your comprehensive record will make their
interaction with your patient more clinically effective and financially
rewarding.
As a reference for official reports: A comprehensive,
well-organized medical record will also help you to prepare reports efficiently
and effectively. This will save you time (and thus generate income), especially
when the preparation of a medical report is non-insured.
As evidence in a medical record audit: When SLP accept their independent licence to
practise from college and Ministry of Health / Health Authority , they agree to
comply with and be accountable to all of the rules, regulations and standards
of both regulatory bodies. The college or ministry can request copies of your
records from any clinical encounter, at any time, for a random review. If the
college review reveals that either your record-keeping or the care documented
in these records is substandard, then a more formal review will be initiated
and disciplinary action can be mandated. If a Ministry of Health review of your
record does not justify the fees you submitted for that clinical encounter,
then a more formal review may follow and you can be required to reimburse the
ministry for all alleged overbilling. This can be catastrophic, and all costs
for defending and appealing a Ministry of Health decision will be your
responsibility.
Disciplinary reviews: You can best defend yourself and your actions
in a malpractice suit or formal review of billing practices if you have medical
records that stand alone without your interpretation. Comprehensive
documentation and legible record-keeping are essential.
HOW LONG SPEECH LANGUAGE PATHOLOGIST/THERAPIST MUST KEEP MEDICAL
RECORDS?
For certainty, reference your own
province’s regulations, but, in many jurisdictions, the following rules apply:
·
10 years after the last entry, or
·
10 years after the patient would have reached 18
years of age, or until the SLP’s ceases to practise (subject to, in the Ontario
example, subsection 2 of the Regulated Health Profession Act, which states that
a family SLP’s who ceases practice must transfer the records to a colleague
with the same address and phone number, or
·
Notify each patient that records will be destroyed
in two years unless the patient requests transfer of their records to another
doctor).
·
Note that legal claims against SLP’s can be made
up to 15 years after the alleged incident occurred, so the CMPA advises doctors/
Paramedical professionals to keep their records for 15 years after the last
encounter.
Many family doctors/SLP’s/Paramedical
professionals who cease practice either are not aware of these requirements, or
fail to follow the rules. As one can imagine, it would be very costly to
contact every patient by phone or mail if the retiring doctor cannot find a
physician/SLP’s to assume the practice. Ignorance is not a defence, however.
There are now several companies that offer medical record storage and retrieval
for
Physicians/SLP’s who close their
practices or retire. Ensure that you verify that such a company meets your
college requirements, especially if the company is located out of province.
Some provincial medical associations administer a medical record storage and
retrieval service for retiring family physicians/ Paramedical professionals,
making records available to patients who request their medical information.
CLINICAL RECORD KEEPING IN SPEECH-LANGUAGE PATHOLOGY FOR HEALTH CARE
AND THIRD-PARTY PAYERS (INSURANCE)
This document is intended to
serve as a guide for speech-language pathology programs in establishing,
revising, and maintaining accurate and appropriate clinical records. It
encompasses American Speech-Language-Hearing Association (ASHA) standards, as
well as those of outside organizations that develop documentation requirements,
including the Centers for Medicare and Medicaid Services (CMS; www.cms.hhs.gov), the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), and the
Commission on Accreditation of
Rehabilitation Facilities (CARF). Regulations such as the Health Insurance
Portability and Accountability Act (HIPAA) have been considered for those
speech-language pathologists who are covered entities under this law (see
www.hhs.gov/ocr/hipaa/ for more information). Additional concepts and practical
suggestions from clinical facilities also are included. Readers are encouraged
to confirm documentation requirements on an ongoing basis with employers, state
and federal agencies, and professional organizations, as regulations and laws
may change over time.
This document does not address
issues surrounding documentation in school settings or as related to the
Individuals with Disabilities Education Act (IDEA). Information about IDEA and
paperwork can be obtained through ASHA’s Web site at www.asha.org.
Clear and comprehensive records
are necessary to justify the need for treatment, to document the effectiveness
of that treatment, and to have a legal record of events. According to the
ASHA’s Code of Ethics, Principle I, Rule K, “Individuals shall adequately
maintain and appropriately secure records of professional services rendered,
research and scholarly activities conducted, and products dispensed and shall
allow access to these records only when authorized or when required by law”
(ASHA, 2003).
Excellent record keeping does not
guarantee good care, but poor record keeping poses an obstacle to clinical
excellence (Kibbee & Lilly,1989)
KEY ISSUES
|
Ø Documentation plays a critical role in communicating to third-party
payers the need for evaluation and treatment services (Medical necessity) and
why those services require the skill of the SLP
Ø Documentation is read by clinicians as well as claims reviewers from
varying backgrounds and experience, therefore notes and reports are to be
clear and legible and that they efficiently convey all of the essential
information that is needed for clinical management and reimbursement.
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IMPORTANCE OF ACCURATE DOCUMENTATION
Ø
Comprehensive evaluation reports helps plan care
Ø
Written reports and notes facilitate
communication and continuity of care among professionals
Ø
Documentation is the foundation for proper
coding and billing
Ø
Records enhance utilization review (analysis of
the kinds of services provided)
Ø
Clinical documents are, in essence, legal
documents if the necessity of your services is challenged
Ø
Documentation is the evidence that your services
are in compliance with state and payer rules and regulations.
SCDHHS MEDICAID-CLINICAL RECORDS
Ø
As a condition of participation in the Medicaid
program, providers are required to maintain and allow appropriate access to
clinical records that fully disclose the extent of services provided to the
Medicaid beneficiary. The maintenance of adequate records is regarded as
essential for the delivery of appropriate services and quality health care.
Providers must be aware that these records are key documents for post-payment
review. If clinical records are not completed appropriately, previous payments
made by SCDHHS may be recovered. It is essential that each provider conduct an
internal records review to ensure that the services are medically necessary and
that service delivery, documentation, and billing comply with Medicaid policy
and procedure. Providers are required to maintain a clinical record on each.
Ø
Medicaid-eligible child that includes
documentation of all Medicaid-reimbursable services. This documentation must be
sufficient to justify Medicaid payment. Clinical records must be current, meet
documentation requirements, and provide a clear descriptive narrative of the
services provided and progress toward treatment goals. The information in the
Clinical Service Notes must be clearly linked to the goals and objectives
listed in the Individualized Treatment Plan (ITP). For example, descriptions
should be used to clearly link information from goals and objectives to the
interventions performed and progress obtained in the Clinical Service Notes.
Clinical records should be arranged logically so that information may be easily
reviewed, copied, and audited.
ASHA CODE OF ETHICS –DOCUMENTATION
Ø
I.Q: 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.
Ø
I.T: Individuals shall provide reasonable notice
and information about alternatives for obtaining care in the event that they
can no longer provide professional services.
Ø
III.C: Individuals shall not misrepresent
research and scholarly activities, diagnostic information, services provided,
results of services provided, products dispensed, or the effects of products
dispensed.
Ø
III.D: Individuals shall not defraud through
intent, ignorance, or negligence or engage in any scheme to defraud in
connection with obtaining payment, reimbursement, or grants and contracts for
services provided, research conducted, or products dispensed.
Ø
IV.C: Individuals' statements to colleagues
about professional services, research results, and products shall adhere to
prevailing professional standards and shall contain no misrepresentations.
Ø
IV.E:
Individuals shall not engage in dishonesty, negligence, fraud, deceit,
or misrepresentation.
SC CODE OF ETHICS: DOCUMENTATION
Ø
Rule 4c: Individuals shall not misrepresent
diagnostic information, services rendered, or products dispensed or engage in
any scheme or artifice to defraud in connection with obtaining payment or
reimbursement for such services or products.
Ø
Rule 5d: Individuals shall maintain
documentation of professional services rendered.
Ø
Rule 6b: Individuals shall not engage in
dishonesty, fraud, deceit misrepresentation, or any form of conduct that
adversely reflects on the professions or on the individual’s fitness to serve
persons professionally.
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What an audit
team Investigator is looking for……………….
|
Ø
Rationale: Otherwise there is a large assumption a clinician
is acting on his or her own accord and quite possibly could be conjuring up a
non-existent problem.
Ø
2. Signed Medical/Billing Release Statement (to
treat and bill)
Ø
Rationale: This is a MUST. If you do not have this consent, it is a
fault line and you will pay 100% back
Ø
Why? Because you do not have permission to
access the minor’s insurance source for payment. PERIOD, much less touch the
child to render medical service.
3. Documentation
Ø
Rationale: NO notes; Big trouble; Big time. Why?
Ø
To investigators,
particularly, the SC Attorney General, there is no proof a speech problem
really exists. You cannot prove it.
Ø
To
investigators, you could be documenting on completely normal kids for money.
Ø
That is
how they view it from the moment a clinician gets flagged.
BOTTOM LINE:
Ø
A
clinician cannot bill for services, receive the funds, then leave the
supporting financial system with a question mark as to whether the services
ever truly took place or as to whether the child really even has a deviancy
in need of intervention.
Ø
It is
so serious, ASHA and SCLLR have joined forces to combat this form of
unethical conduct and to restore esteem to our profession, as a whole
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|
AUDIT :
|
|
Ø
It is
essential that internal audits be conducted by the provider to ensure that
the services provided are medically necessary and appropriate both in quality
and quantity, and those services are being billed appropriately. Missing or
incomplete documentation could result in recoupment of funds.
Ø
MEDICAL
RECORDS AUDITS Medical records may be audited at the request of ATC to
determine compliance with ATC’s standards for documentation. Medical records
may also be audited to validate coordination of care and services provided to
members, including over/under utilization of specialists; ensure providers
are following National and State coding guidelines (i.e. National Correct
Coding Initiatives, Centers for Medicare & Medicaid Services, SCDHHS); as
well as the outcome of such services may be assessed during a medical record
audit.
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MOLINA MANUAL: FRAUD AND ABUSE
PRINCIPLES OF DOCUMENTATION
•
Documentation
must be:
Ø
Accurate: describes the care provided
Ø
Code-able:
supports CPT, ICD-10
Ø
Understandable:
clear to reader (and not just to another SLP)
Ø
Timely:
entered when the service is provided
Ø
Error
free: stands alone as a legal document
THE DOS OF DOCUMENTATION
Ø
If it
wasn’t documented, it wasn’t done!
Ø
Every episode of care must be documented
Ø
All documentation must be dated and signed
Ø
Document in a timely way- that is, when the
service was provided
Ø
Anecdotal or historical events (patient not
present) should be documented
-Phone
conversations/emails etc
Ø
Do use professional language that demonstrates
your clinical skill
Ø
Do report objective data to support goals
Ø
Do explain your decision making/rationale for
treatment and recommendations
THE DON’TS OF DOCUMENTATION
Ø
Don’t over-abbreviate or use jargon
Ø
Don’t copy/paste notes without editing and
personalizing
Ø
Don’t make up information
Ø
Don’t document when it was someone else who
provided the service (You can amend a note if you have new information, but you
must sign the amended note yourself.)
|
What is required
to Ensure Accuracy (Compliance)?
|
|
Ø
Billing
codes must match documentation
Ø
Documentation
must support the scope and level of service (complexity or time)
Ø
CPT
code (s) must correlate with the diagnosis code(s)
Ø
Services
must be appropriate by provider type
Ø
Physicians
orders
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SKILLED VS UNSKILLED
SERVICES
Ø
Unskilled services do not require the special
knowledge and skills of a speech-language pathologist. Skilled services that
are not adequately documented may appear to be unskilled. Examples of
documentation that do not describe a skilled service are listed below:
Ø
reporting on performance during activities
without describing modification, feedback, or caregiver training that was
provided during the session (e.g., patient was 80% accurate on divergent task;
patient tolerated diet [or treatment] well);
Ø
repeating the same activities as in previous
sessions without noting modifications or observations that would alter future
sessions, length of treatment, or POC (e.g., continue per POC, as above);
Ø
reporting on an activity without connecting the
task to the long- or short-term functional goals (e.g., patient has treatment
plan to address intelligibility related to dysarthria, but the note simply
states "patient able to read a sentence and fill in the blank on 90% of
trials");
Ø
observing caregivers without providing education
or feedback and/or without modifying plan.
SLPs use their expert knowledge
and clinical reasoning to perform the skilled services listed below. SLPs
Ø
analyze medical/behavioral data to select
appropriate evaluation tools/protocols to determine
communication/cognitive/swallowing diagnosis and prognosis;
Ø
design a plan of care (POC) that includes length
of treatment and establishes long- and short-term measurable functional goals
and discharge criteria;
Ø
develop and deliver treatment activities that
follow a hierarchy of complexity to achieve the target skills for a functional
goal;
Ø
modify activities, based on skilled observation,
during treatment sessions to maintain patient motivation and facilitate
success;
Ø
increase or decrease complexity of treatment
task and increase or decrease amount or type of cuing needed;
Ø
increase or decrease criteria for successful
performance (accuracy, number of trials response latency, etc.);
Ø
introduce new tasks to assess the patient's
ability to generalize a skill;
Ø
engage patients in practicing behaviors while
explaining the rationale and expected results and/or providing reinforcement to
help establish a new behavior or strengthen an emerging or inconsistently
performed one;
Ø
conduct ongoing assessment of patient response
in order to modify intervention based on patient performance in treatment
activities, patient report of functional limitations, and/or progress;
Ø
ensure patient/caregiver participation and
understanding of diagnosis, treatment plan, strategies, precautions, and
activities through verbalization and/or return demonstration;
Ø
train and provide feedback to
patients/caregivers in use of compensatory skills and strategies (e.g., feeding
and swallowing strategies, cognitive strategies for memory, and executive
function);
Ø
develop, program, and modify augmentative and
alternative communication systems (low tech or high tech);
Ø
train in the use and care of communication
system;
Ø
instruct patient and caregiver in use and care
across communication levels (word-conversation) as appropriate, based on patient's
prior level of function or desired long-term goal;
Ø
develop maintenance program—to be carried out by
patient and caregiver—and train caregivers to facilitate carryover to ensure
optimal performance of trained skills and/or to generalize use of skills;
Ø
evaluate patient's current functional
performance for patients with chronic or degenerative conditions and provide
treatment to optimize current functional ability, prevent deterioration, and
establish and/or modify maintenance program;
Ø
determine when discharge from treatment is
appropriate.
CLINICAL RECORD KEEPING
PROCESS
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Policy Statement
|
|
Recordkeeping is used to document the condition and
care of the patient, avoid or defend against a malpractice claim and support
the concurrent and/or retrospective medical necessity requiring the provision
of skilled services. The provider is responsible for documenting the evidence
to clearly support the afore cited indices and submitting the documentation
for review in a timely manner.
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I. The Documenter (Who)
A. Usually
the person who renders the assessment, care, or treatment.
B. In
emergency situations, the person designated to document a detailed
account
of the situation.
II. Components of Clinical Record Keeping (What)
A. Identifying information.
1.
Facility name and client’s clinic or medical record number.
2.
Client name and related identifying information (address, e-mail,telephone
number(s),
date of birth, language(s) spoken, and caregiver/legally responsible
person to whom
information can be released).
3. Client Health
Insurance Claim Number (HICN) or social security number/ID.
4.
Speech-language pathologist’s (SLP) name, certification, licensure (as
applicable), and
related identifying information.
5.
Referral source, related identifying information (e.g., Universal Physician
Identification
Number), reason for referral, and date (if applicable).
6. Date
report prepared.
7.
Evaluation date.
8.
Treatment period covered by report.
9.
Signed notice of privacy rights (HIPAA-covered entities).
10.
Signed authorization to release information (as applicable)
B. Client history.
1.
Medical diagnosis(es) (primary, secondary, including date[s] of onset).
2. Communication or swallowing disorder
diagnosis(es) and onset date(s).
3.
Medical history pertinent to speech, language, cognitive communication, or
swallowing
treatment, including surgical procedures.
4.
Educational status/occupational status (as appropriate).
5.
Relevant history of language development, including language(s) spoken across
various
environments and age of onset of language(s) learned.
6.
Prior functional communication status, considering the framework of the
International
Classification of Functioning, Disability, and Health (ICF):
a. Body functions and structures
b. Activity and participation
c. Environmental factors
d.
Personal factors
e. Contextual factors.
7. Prior speech, language, cognitive-communication,
or swallowing treatment,
outcome of that treatment, length of prior
treatment.
8. Additional pertinent information
(e.g., medical records, educational testing,
observations).
9. Source(s) of client history.
C. Assessment of current client status.
1. Date
of initial assessment or reassessment.
2.
Initial functional status of client, considering the ICF framework, based on:
a.
Baseline testing using standardized and non-standardized measures.
b.
Modifications of standardized assessment procedures utilized, including, but
not
limited to:
i. Use of interpreter
ii.
Translated assessment
iii.
Use of gestures to elicit responses
iv.
Other.
c.
Interpretation of test scores/results.
d.
Statement of severity.
e.
Other clinical findings, including those from other specialists or team
members.
3.
Documentation that speech-language pathology evaluations consider a client’s
hearing,
vision,
motor, and cognitive status.
4. Documentation that assessment
tools were evaluated for ecological validity and determined
to
be appropriate for the client.
5. The
language(s) in which the assessment was conducted.
6.
Person(s) present during the evaluation (e.g. professional interpreter, family
member,
etc.).
7.
Statement of prognosis.
8.
Recommendations based on the client’s functional needs and medical necessity,
including
referrals, as appropriate (see Admission/Discharge Criteria in
Speech-Language
Pathology; ASHA, 2004).
9. Signature and title of qualified professional
responsible for the assessment (and that of
documenter, if different).
D. Treatment plan.
1.
Date that plan of treatment was established.
a. For Medicare patients, the plan of care must be established and
certified by a
physician
before treatment begins. Plan of treatment must be recertified by the
physician on a regular schedule (every 30 or
60 days, depending on the setting).
2.
Short- and long-term functional communication or swallowing goals.
a. Should
reflect desired client outcomes: the level of communication
independence
the client is expected to achieve based on input from the client
and/or family.
b.
Should reflect culturally and linguistically appropriate services.
Reimbursable,
functional communication goals should not include features that are due
to
communication differences.
3.
Treatment objectives.
4.
Recommended type and expected amount (e.g., 1 hour sessions, individual or
group),
frequency (e.g., three times per week), and duration (e.g., 3 months) of
treatment.
5.
Follow-up activities.
6. Statement of prognosis specific to
long-term goal(s).
7.
Date treatment plan was discussed with client and/or family.
8.
Date interdisciplinary conferences were held, if applicable.
9.
Statement of schedule for review of the plan.
10.
Signature and title of qualified professional responsible for treatment plan
E. Documentation of treatment.
1. Date client
began treatment at present facility.
2. Time period
covered by report (date of treatment[s]).
a.
Frequency of documentation is determined by facility guidelines, payer
requirements, and
professional preference. In some cases, documenting each
session may be valuable, such as when appealing an insurance denial.
3. Summaries of
assessment and treatment plan in treatment reports.
4. Current client
status.
a. Communication or swallowing diagnosis.
b.
Objective measures of client communication or swallowing
performance in functional terms that relate to treatment
goals.
c. Use of consistent reporting (use same method during each
treatment session to track progress toward short- and long term
goals or explain rationale for changing method).
5.
Any changes in prognosis (include significant developments).
6. Any changes in plan of treatment.
7.
Description of the need for continued intervention, if applicable.
8.
Signature and title of qualified professional responsible for treatment services
(and
that of documenter, if different). Note: The supervisor of noncertified personnel,
including persons in their Clinical Fellowship (CF), should sign all
records, unlessother
requirements are stated. For example, Medicare recognizes ASHA’s
standards for
supervision of CFs, and co-signatures by the supervisor are required
only when direct
supervision of care has occurred. (Refer to Medicare guidelines
regarding the use of
also sign all evaluation reports and discharge summaries.
F. Discharge summary.
1.
Follow-up recommendations (see Admission/Discharge Criteria in Speech-Language
Pathology; ASHA, 2004).
2. Establishment of a maintenance program, if applicable.
G. Record of
consultation.
1.
Consultation with other professionals.
2.
Consultation with client and caregivers or legally responsible parties.
H. Correspondence
pertinent to individual client.
III. Storage (Where)
A. General information.
1.
In secure place, to be accessed only by authorized personnel.
2.
Safeguarded against loss or destruction.
3.
Refer to HIPAA Privacy and Security rules, as applicable.
B. Historical
clinical records.
1.
Maintained through computer storage.
2.
In secure yet less accessible place (away from current files).
IV. Time Frame for Recording, Sending, and Retaining Client Information
(When)
A. Recording.
1. According to time frame set by:
a.
National, state, and accrediting body standards.
b.
Facility.
c.
Department.
B. Sending reports
and information to other professionals and client and/or family.
1. According to a specified time frame
as discussed above.
C. Storage and
maintenance of historical clinical records.
1. According to schedule for filing and transferring historical files for
archival storage.
2. According to state and federal law or, when no law exists, a created
policy that
reflects client/patient and program needs.
a. States may have differing regulations (refer
to state Department of Health
regulations regarding medical record retention).
b. Various Medicare regulations stipulate
that, in the absence of a state
statute,
medical records must be kept for a minimum of 5 years after date of discharge. HIPAA
regulations require that records be retained for a minimum of 6 years after
discharge or 2 years after a patient’s death
(see www.hipaadvisory.com/regs/recordretention.htm for more
information).
c. Records for minors may need to be kept
longer, possibly until the minor
reaches the age
of 21.
d. Professionals should abide by the most
stringent regulations regarding record retention.
2. Client or caregiver permission or
notification does not permit earlier destruction of medical
records.
3. Record keeping
procedures may vary by facility or program.
4. Disposal of obsolete
records should be in a manner that protects the confidentiality of client
information.
V. Rationale for Documentation (Why)
A.
Reasons for appropriate documentation.
1. Justify initiation and continuation of treatment.
2. Support the diagnosis and treatment (including medical necessity
and need for skilled services).
3. Describe client progress.
4. Describe
client response to interventions.
5. Justify discharge from care.
6. Support reimbursement.
7. Communicate with other practitioners.
8. Facilitate quality improvement.
9. Justify clinical decisions.
10. Document communication between involved
parties
(practitioners, client, caregivers, or
legally responsible parties).
11. Protect legal interests of client,
service provider, and facility.
12. Serve as evidence in a court of law.
13. Provide data for continuing education.
14. Provide data for research (i.e.,
efficacy).
VI. Methods (How)
A. Clinical
record keeping should:
1. Conform to federal, state, and local laws.
2. Adhere to
facility’s standards and regulations.
B. Electronic
documentation systems (paperless) are acceptable if supported
with
appropriate technology to ensure accessibility, usability, and privacy.
C. Writing should
be clearly understood by the reader; that is, content should be:
1. Accurate, concise, and informative.
2. Adapted for a potentially large
readership.
3. Useful and relevant to other staff.
4. Neat and legible, if handwritten.
D. Clinical records
should be consistent in format and style.
1. As
established by facility (e.g., SOAP note format—Subjective, Objective,
Assessment,
Plan
[Miller & Groher, 1990]).
a. Preprinted
forms or standard formats for reports should be established.
b. Use of
checklists versus narrative accounts is at the discretion of the clinician and
facility.
c. No universal
documentation template exists.
2.
Using appropriate International Classification of Diseases and Related Health
Problems
(ICD) codes, current revision (U.S.Department of Health and Human
Services).
3. Using appropriate Current
Procedural Terminology (CPT) codes, current revision
(American Medical
Association).
4.
Using appropriate terminology per ASHA policies and currently accepted terms.
5.
Using appropriate and acceptable abbreviations (see JCAHO patient safety goals
regarding the use of abbreviations in medical records).
6. Individual payers may have
different documentation requirements. Typically, health
plans are instructed by law to request
only the minimum information necessary to
pay the claim.
E. Clinical records
need to be organized with entries recorded chronologically.
F. The documenter
must assure accuracy by:
1.
Proofreading documentation to verify that the meaning is clear.
2.
Appropriately correcting an entry (i.e., crossing out incorrect material with
one line,
writing reason for change, entering the correct information, and dating
and initialing
the correction; no use of “white out”).
G. The documenter
should provide rationale for such clinical decisions as test selection
(including
sensitivity
to the population to which it was administered), diagnosis, prognosis,
treatment
goals, and recommendations.
H. The documenter
must be sensitive to client rights by:
1.
Including signed documentation about consultation with client, caregiver,
and/or
legally responsible parties.
2. Obtaining signed and dated
release of information forms or authorizations in
with state and federal
policy whenever documents are released or information is
disclosed.
I. Clinical
records must be treated as a legal document by:
1. Ensuring that records are written in ink or computer-generated for
permanence.
2. Signing all record entries with name and professional title of primary
service
provider
and all appropriate professionals.
3.Dating and initialing
materials from other facilities before entering them into
permanent record.
Note: for legal purposes, records need to be thorough,
accurate, and
include all necessary signatures and release authorizations.
J. A quality
improvement process for record maintenance should be instituted, such as:
1. Conducting a records review to ensure that records are complete, accurate,
and
maintained
on a proper schedule.
2. Developing troubleshooting techniques by:
a. Predicting potential problems.
b. Planning response to remediate each
problem.
c. Following up on each problem.
3. Developing checklists for completing each form so that it is
completed
accurately the first time
K. Clinical records must be kept in an organized and systematic
fashion, for example:
1. If kept as hard files, keeping a chronological log on inside of folder
for easy
reference
to list dates and services provided, name or initials of provider, and
other client identifying information (contact sheet).
2.Safeguarding
against loss (e.g., affix records to record jackets, backing up
computer
systems).
3.Separating current
from historical files and storing them appropriately.
4. Indicating where
and to whom reports are sent (e.g., appropriate
cc notations on
reports and consistent notations on contact sheets).
VII. Additional Considerations
A. Medical/clinical records are the property of the facility, unless
otherwise
provided by law (refer to state
regulations).
B. All information and records are confidential
unless otherwise provided by law.
C. Confidentiality of records and
patient privacy are of paramount concern
(see HIPAA regulations regarding
Protected Health Information [PHI] and privacy).
D. For reimbursement purposes, documentation
needs to prove that professional
treatment is warranted. That
is, there must be evidence of functional deficits requiring
intervention (medical
necessity) only by a skilled professional (skilled services) who is
qualified to assess client needs, plan and
implement effective treatment, and consider
(and prevent) potential
medical complications. Elective services, such as accent
reduction, are not typically
reimbursable from a third-party payer and these guidelines
need not apply.
E. Records should be organized according to alphabetical or numerical
order. Records and
files should be organized
systematically so that they can be accessed and understood by
all potential readers,
including the original documenter in future years.
F. In medical facilities, regulations differ as to who can write orders
or take verbal orders in a
patient’s medical chart. Refer
to specific facility policy and/or applicable state law.
PROGRESS NOTES
Progress notes are the core of
most clinical records. records. They provide a record of events, are a means of
communication among professionals, encourage us to review and assess treatment
issues, allow other professionals to review the process of treatment, and are a
legal record. Progress notes have also seen increasing use by insurance
providers seeking to determine whether a treatment is within the realm of
services for which they provide compensation ( Kagle, 1993). In writing
progress notes, you must keep all these functions in mind.
TYPES OF PROGRESS NOTES
The two most common types of
progress notes are problem-oriented and goal-oriented notes. As the names
suggest problem oriented notes refer to one or more specific problem areas
being addressed in treatment( Cameron& Turtle-song,2 001;Weed,1971),whereas
goal-oriented notes focus on specified treatment goals, with each entry
relating in some way to a goal. In systems that use problem- or goal-oriented
notes, each therapist, or the treatment team as a group, identifies several key
areas of focus in the client's treatment. For example, problems might be
identified as:
l. Initiates fights with other
residents
2. Does not participate in social
interactions
Expressed as goals these might be
stated:
1. Reduce incidence of instigating
fights
2. Increase socialization
Once a list of the problems or goals is established progress notes then
refer to them by number or name. The theory behind this approach is that it
helps staff target their intervention to meet specific treatment needs or
goals. Such notes may also help demonstrate to insurers that the treatment provided
is systematic and is related to specific problems or goals for which
compensation is being provided.
STRUCTRUED NOTE FORMATS
DART NOTES
POMR NOTES
SOAP NOTES
DART NOTES
The DART system is most useful
when you are writing notes about a specific client or event. The D in DART
stands for a Description of the client and situation A. is for Assessment of
the situation. (This A was originally 1, which stood for the clinician's impression and produced the initial
acronym.)R is for the Response of the clinician and client, and T is for
Treatment implications and plan.
POMR NOTES
The POMR /Problem Oriented
Medical Records system ( Cameron& Turtle-song,2002 Weed,1 971) as initially
defined by Lawrence Weed, MD, is the official method of record keeping used at
Foster G. Mc Gaw Hospital and its affiliates.
Many physicians object to its use for various reasons - it is too
cumbersome, inhibits data synthesis, results in lengthy progress notes, etc. However,
the proper use of the POMR does just the opposite and results in concise,
complete and accurate record keeping. A
brief overview of the salient features of the POMR will be helpful.
The basic components of the POMR are:
1. Data Base - History, Physical Exam and
Laboratory Data
2. Complete Problem List
3. Initial Plans
4. Daily Progress Note
5. Final Progress Note or
Discharge Summary
SOAP NOTES
One of the more common
standardized note taking methods is the SOAP format. So-called SOAP notes are actually
part of a broader system known as Problem Oriented Medical Records. The letters
in SOAP stand for subjective, objective, assessment, and plan.
"Subjective" refers to information about the client's present situation
from the client's subjective position. One way to think of this is as the
client's presenting complaint or description of how he or she is doing and what
he or she needs or desires.
"Objective" information
is meant to be the external data that are being observed. In a medical setting,
this might be blood pressure, temperature and the like. Such objective data are
often much less clear in speech therapy interactions than in medical practice,
though it is possible to offer descriptions of, for example, the client's
affect, appearance and mannerisms. The "assessment” Portion of a note
reflect show the therapist integrates and evaluates the meaning of the client's
subjective report and the objective extremely observable data in light of all
the other information known about the client. From this assessment the plan of
treatment action is then recorded.
THE PURPOSES OF DOCUMENTATION
All HealthCare professionals document their findings for
several reasons:
1. Notes record what the therapist does to manage the individual
patient’s case. The rights of the therapist and the patient are protected
should any question occur in the future regarding the care provided to the
patient. SOAP notes are considered legal documents, as are all parts of the
medical record.
2. Professionals providing services after the patient is
discharged from one therapist’s care may find the therapist’s notes to be very
valuable in providing good follow up treatment.
3. Using the SOAP method of writing notes helps the
therapist to organise the thought processes involved in patient care. By
thinking in an organised manner, the therapist can better make decisions
regarding patient care. Thus, the SOAP note is an excellent method of
structuring thinking for problem solving.
4. A SOAP note can be used for quality improvement purposes.
Certain criteria are set to indicate whether quality care is occurring. Within
a limited time frame, the SOAP notes from all patients with a certain diagnosis
can be assessed to see whether the preset criteria have been met.
THE RELATIONSHIP OF SOAP NOTES TO
THE DECISION MAKING PROCESS
As mentioned previously, using SOAP notes helps the
therapist organise and plan quality patient care. Following the SOAP note
format presented in this workbook provides structure within which good problem
solving can occur.
1. The therapist reads the patient’s chart (medical record)
or referral (if either is available).
Test results such as x-ray examinations and laboratory
findings as well as the physician’s impression of the patient’s problem can
assist in planning the patient interview and identifying measurements to be
performed.
The results from this portion of the process are stated in
the section called Problem or Diagnosis.
2. The therapist then interviews the patient. Information is
gathered regarding the patient’s history, complaints, home situation and goals
for therapy. The subjective information thus gathered comprises the Subjective,
or S, portion of the note.
3. From the information gathered from the medical record and
the patient, the therapist plans the objective measurements to be performed.
Then the planned measurements are completed. The results of these measurements
performed are recorded in the Objective, or O, portion of the note.
4. Once the therapist has completed the interview and
measurement process, they interpret the information recorded and identifies
factors that are not within normal limits for people in the same age range as
the patient. From these factors, the therapist formulates a list of the
patient’s problems, including functional limitations and impairments.
The patient’s problems are recorded in a section of the note
called Functional Limitations or the Problem List, depending on the facility
and what it includes in this section. Functional Limitations or the Problem
List is part of the Assessment, or A, portion of the note.
5. After formulating a list of the patient’s functional
limitations or problems, the therapist and the patient together establish goals
that correspond to the patient’s functional limitations or problems. The first
set of goals, or functional outcomes, states the final result of therapy, or
the extent to which each of the patient’s functional limitations or problems
should be resolved following a program of therapeutic intervention.
The goals stating the intended outcomes of therapy are
called Functional Outcomes or Long Term Goals. The Functional Outcomes or Long
Term Gaols are also included in the Assessment, or A, portion of the note.
6. Once the goals are established, the therapist and patient
consider what can be achieved within a short and long period of time.
The goals stating what can be achieved in a short period of
time are called Short Term
Goals. The Short Term Goals are written into the Assessment,
or A, portion of the note.
7. Once the therapist and the patient together make
decisions regarding the anticipated outcomes or goals of treatment, the
therapist formulates impressions of the patient’s problems and conditions.
Justifications of unusual goals or patient parameters that could not be
measured or cannot be treated as listed.
The therapist’s Summary and/or Impressions are listed in the
Assessment, or A, part of the note.
8. After setting goals with the patient, the therapist
outlines a treatment plan to achieve them.
The plan for treatment is listed as the Plan, or P, part of
the note.
|
MAIN PURPOSE:
|
|
· Maintaining documentation largely guided by state
requirements as well as by the accrediting agency
· Helps justify treatment decisions:
· Helps examine the patient’s response to past treatments
and helps guide future treatment planning
· Facilitate continuity of treatment if there is a change in
therapist
· Prove what you did matches what you charged for should you
be audited
· Communicates progress to parents/caregivers
· If need to testify years after services, written record is
all you have to go by
·
“If it
wasn’t documented, it wasn’t done”
|
S-SUBJECTIVE
š Statement about relevant patient
behavior or status
š Client reports of limitations,
concerns, problems, progress
š Information from the family or
caregiver pertinent to the session or progress
š Any personal or medical issues that
may influence performance
· Medication Changes
š Patient’s manner or behavior
·
Mood
·
Motivation
·
Participation
š If it’s not relevant, don’t
document
·
Patient
complained about previous therapist.
·
Patient
stated he had fun at the water park this past weekend.
O-OBJECTIVE
š Measurable, quantifiable, and
observable data
· Percentages of any goals/objectives
addressed in therapy
š May include type of treatment given
· Specific Exercises
· Functional Tasks
· Assistance and devices required
š Don’t provide a global summary
A-ASSESSMENT
š Interpret the meaning of “S” and “O”
·
What does your data actually mean?
·
Factors impacting the patients
ability to attain goals?
š Compare patient’s performance across sessions
§
Did the patient improve? Decline?
§
Did you use less cues? More cues?
PLAN
š The three Ps
·
PLAN:- Problems, Progress, Potential
The Three Ps
Problems : Areas that keep the
patient in treatment
•Decreased fine motor coordination
affects the patient’s ability to write name
•Perseveration with lining up toys
limits the patient’s social interaction with peers at school
•Decreased speech intelligibility
impacts patient’s ability to communicate effectively with
family and peers
Progress : Observed
Improvements
•Patient’s progress toward
handwriting goals has been limited due to recent right radius
fracture and casting of
dominant right upper extremity
•STG related to /s/ production in
words was met this week
Potential : Potential success in therapy
•Patient’s
progress in ability to use scissors indicates good potential to meet goals
•Patient’s
progress in conversational turn-taking indicates good potential to form
successful
social relationships
•Patient’s progress in identifying and
correcting errored productions of /s/ indicates good
potential to meet goals
SOAP DOCUMENTATION GUIDELINES
Initial assessment only – 1 line - reason for referral /
history of presenting condition
S - Subjective
Information that is reported by the patient, family or
others (carers, health care professionals etc) including the client’s
perception of the problems. This could include areas such as:
· Swallowing
· Eating
· Communication
· Cognition
· History of communication, swallowing
and / or cognitive difficulties
· Relevant medical and developmental
history
· Impact of communication, swallowing
and / or cognitive difficulties on function
· Past Speech Pathology management
· Motivation for therapy
· Other agencies involved
O – Objective
Presentation, general
observations
Clinical findings and measurements – Tests you have utilized
and scores/measures derived must be documented.
The following assessment items may be commented on:
18yrs+
· Receptive Language (verbal, written)
· Expressive Language (verbal, written)
· Cranial Nerve Function
· Cognition
· Motor speech
· Swallowing
· Voice
· Pragmatics
· Fluency
0-18yrs
·
Feeding,
swallowing, saliva control
·
Speech
(Articulation, Phonology
·
Receptive
Language
·
Expressive
Language
·
Literacy
(reading, writing, spelling, phonological awareness)
·
Voice
·
Fluency
·
Pragmatics
·
Nature
and outcome of therapy is also documented here.
A - Assessment /Analysis
This section includes your overall summary and
interpretation of subjective and objective information. You must state the
level of impairment, disability and handicap and include severity levels for
these such as mild, moderate and severe.
You may make comparisons with test results from other areas
in your analysis here such as chest X-ray results, CT results, Apgar scores
This section will include:
Goals and therapy foci
Estimate length of treatment program and frequency of
treatment
P - Plan / Management
Recommendations
In this section you document what the patient requires/what
you plan to do. This section may include:
·
Diet
recommendations
·
Communication,
swallowing, and cognition recommendations and strategies
·
Provision
of information and education
On referrals eg. To Psychology, ENT, Pediatrician , Specialist etc…
SMART OBJECTIVES/GOAL
Developing SMART Objectives/Goal
One way to develop well-written objectives is to use the
SMART approach. Developing
specific, measurable objectives requires time, orderly
thinking, and a clear picture of the
results expected from program activities. The more specific
your objectives are, the
easier it will be to demonstrate success. Moreover, a goal
should be measurable: Quantifiable,
Calculable, Assessable, Determinate, Computable, Finite, Clear and Verifiable
Writing Source: ASHA: Writing
measurable goals and objectives adapted from Hamilton County Educational
Services Center Smart Sheet, Chalfant and McGraw 4/2004.
SMART Goals
-Specific/Significant
-Measurable/Meaningful (i.e., with metrics/criteria
of mastery
-Achievable/Action-Oriented
-Realistic/Relevant
-Timely/Trackable
“SMART” Objectives are a helpful mnemonic
device for developing impactful and quantifiable indicators of program/project
success.
Specific in identifying outcomes to be achieved
Measurable using
quantifiable and objective terms
Attainable given proposed timeframe & capacity
Relevant
to the
identified problem/statement of need
Time-bound within the
project period
Specific – A specific goal is more easily
accomplished than a general goal. Both the applicant and the donor know what is
expected, and the donor can easily monitor and assess performance against
proposed metrics.
Measurable – Identify indicators that will help
you stay on track to achieving your goals. Progress is regularly monitored
according to these indicators. Shows the applicant and donor what work has been
accomplished toward proposed metrics.
Attainable – Move the needle. Make sure your
objectives will make a measurable effect on the identified problem and targeted
community. Make sure your organization has everything in place to meet metrics.
If you do not reach your metrics, you will need to be able to explain why.
Realistic – Don’t overpromise or overstretch
your organization’s capacity, objectives should be accomplishable within the
specified time period. Consider the types of people, resources, and other
support you will need to accomplish the proposed metrics.
Timely – All objectives should be grounded
within a specific timeframe, usually the grant period proposed by your
organization or identified by the donor. Show what is required and when.
SAMPLES SMART OBJECTIVES/GOALS
1) Examples
of Language Goals
•Long Term Goal (within 6 months):
The patient will increase the use of
expressive vocabulary from 0-25 words with familiar listeners in familiar
settings, to communicate a variety of pragmatic functions with minimal prompts
80% of opportunities in 4/5 consecutive sessions.
•Short Term Goals:
•With multisensory cueing, the
patient will imitate 5 signs/gestures/or word approximations to request,
protest, or greet familiar listeners in structured therapy settings 80% of
opportunities in 4/5 consecutive sessions.
•With fading prompts, the patient
will use 10 signs/gestures/or word approximations to request, protest, greet,
and answer yes/no questions during structured therapy sessions 80% of
opportunities in 4/5 consecutive sessions.
2) Examples
of Speech Goals
•Long Term Goal: The patient will
increase speech intelligibility of 3-4 word phrases from less than 50% in known
contexts with known listeners to 80% in unfamiliar contexts with unfamiliar
listeners.
•Short Term Goals:
• With multisensory cueing, the
patient will identify minimal pairs targeting initial consonant deletion, final
consonant deletion, and fronting from field of 2 with 80% accuracy in 4/5
consecutive sessions.
• With fading prompts, the patient
will produce targeted initial consonants (i.e., /m/, /n/, /h/, and /w/) in
words with 75% accuracy in 4/5 consecutive sessions.
3) Examples
of Speech Therapy Goals
•Long Term Goal:
The patient will advance from
following a 1 step verbal direction to a 3 step verbal direction,
independently, 70% trials, to improve sequencing and memory recall skills used
in functional daily routines.
•Short Term Goals:
•The patient will follow a 2 step
written direction to pick up toys and place them in the appropriate storage
bins with no more than 2 verbal cues for 4/5 trials.
•The patient will follow a 3 step
verbal direction to fold, sort, and put away laundry with no more than 1 verbal
cue for 4/5 trials.
1) Sample
daily notes
•
S- E arrived to session with father
today. He transitioned without cues, however, he cried on and off throughout
session.
•
O/A-2 Language/Articulation E will
imitate the following word types with 80% intelligibility: CVCV, VC. E imitated
CVCV words. He required max cues for /m/, /p/, and /d/. Visual Max 30% 3.
Language E will imitate 40 words, gestures, signs across 3 consecutive
sessions. E required max verbal cues to imitate single words today. Verbal Max
55% 4. Oral Motor E will imitate 5 oral motor movements. E. imitated pucker and
lip smack. Visual Mod 70% 5. Language E. will imitate 2 word phrases, 80%
accuracy. E said "clean up" and word approximations for "all
done". Given max cues he imitated "more" and used sign for
"candy". 6. Verbal Max 25% E made vocal approximations for words
throughout the session. He made the syllable "gaga" for many words.
•
P- Session discussed with father.
Continue current treatment plan.
2) Sample
Daily Note
S:
Child was very pleasant and cooperative.
O: approximated single words x8 including ball, baby, dog, mama, choo choo, apple, duck, Minnie; spontaneously used, monka, bye bye, see you later; followed directions with min cues with 90% accuracy, imitated animal sounds x5
A: increased verbal imitation and spontaneous use of words,
P:continue per POC
O: approximated single words x8 including ball, baby, dog, mama, choo choo, apple, duck, Minnie; spontaneously used, monka, bye bye, see you later; followed directions with min cues with 90% accuracy, imitated animal sounds x5
A: increased verbal imitation and spontaneous use of words,
P:continue per POC
QUARTERLY
PROGRESS REPORT/ DISCHARGE SUMMARY
Ø Summarizes the services provided
Ø Progress on Goals: Clearly describes where the patient was at
the beginning of treatment and where they are now
Ø Client’s current level of function
Ø Recommendations for further therapy
or other evaluations/services
Ø Share this with the referral source
and physician
SCDHHS
MEDICAID: PROGRESS SUMMARY
Ø The Progress Summary is a written note
outlining the child’s progress that must be completed by the provider, at a minimum, every three (3) months from the
start date of treatment. The purpose of the Progress Summary is to
record the long term treatment of the patient, describe the attendance at
therapy sessions, document progress toward treatment goals and objectives, and
establish the need for continued participation in treatment.
Ø The Progress Summary must be written
by the provider, contain the provider’s signature and title as well as the date
written, and must be filed in the patient’s clinical record. The Progress
Summary may be developed as a separate document or may appear as a Clinical
Service
Ø Note: If a Progress Summary is written as a Clinical Service Note,
the entry must be clearly labeled “Progress Summary.”
DISCHARGE SUMMARIES
Ø dates
of treatment;
Ø goals
and progress toward goals;
Ø treatment
provided;
Ø objective
measures (e.g., pre- and post-treatment evaluation results, outcomes measures);
Ø functional
status
Ø patient/caregiver
education provided;
Ø reason
for discharge;
Ø recommendations
for follow-up.
SUMMARY
The SOAP is one of the
more commonly used forms of note writing, it’s very crucial part of medical/clinical record management for speech
language pathologist. The SOAP format lends itself well to writing
an initial note, as well as to writing interim notes and a discharge summary
for each patient seen in therapy. It is probably the most comprehensive form of
document encountered by most practitioners.
Documentation has many purposes, from
assuring quality care to communication to discharge planning. It has become
very important in a HealthCare atmosphere that includes lawsuits and the need
of third-party payers to obtain clear and accurate information. The SOAP method
of writing notes serves as a guide to thinking through problems, demonstrating
accountability for quality patient care, and documenting patient care.
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