Acute Care Documentation: Best Practices for SLPs
Hours: 1.00
This module provides speech-language pathologists with best practices in documentation for the acute care setting. Through a series of case studies, learners will understand how to address and integrate appropriate documentation that clearly communicates the patient’s status to other team members, aligns with standards, and characterizes legally credible documentation. Strategies for using objective measures to assess and document changes in a patient’s condition will be addressed. Pitfalls in documentation will be described, including the legal definition of negligence and documentation practices that can put you at higher risk for liability.
This module provides speech-language pathologists with best practices in documentation for the acute care setting. Through a series of case studies, learners will understand how to address and integrate appropriate documentation that clearly communicates the patient’s status to other team members, aligns with standards, and characterizes legally credible documentation. Strategies for using objective measures to assess and document changes in a patient’s condition will be addressed. Pitfalls in documentation will be described, including the legal definition of negligence and documentation practices that can put you at higher risk for liability.
American Speech-Language-Hearing Association
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Intermediate Level
0.10 ASHA CEUs
Kansas Health Department of Aging and Disability Services (Speech)
Approved for 1.00 continuing education clock hours for Kansas Speech Pathologists and Audiologists by the Kansas Department of Aging and Disability. Long Term Sponsorship number LTS-S1057. This activity is approved for 1.00 contact hours.
Indicate the role of documentation in patient care.
Determine four best practices for documentation in acute care settings.
Identify at least three practices associated with poor documentation.
Outline:
Section 1: Introduction
About This Course
Learning Objectives
Section 2: Documentation Practices
Purposes of Documentation
Laws and Standards
Documentation Basics
Use of Abbreviations
Summary
Section 3: Effective Documentation
Overview
Organizing Your Information
Assessment
Treatment
Education
Goals
Timeliness
Outcomes Measurement
Summary
Section 4: Other Considerations
Point of Service Documentation
Medical Record Corrections
Student Documentation
21st Century Cures Act Final Rule
Ethical Dilemmas
Discharge Documentation
Summary
Section 5: Conclusion
Course Summary
Course Contributors
Resources
References
Meghan Farrington is a certified and licensed speech-language pathologist with over 20 years of experience in the adult setting. Meghan earned her Bachelor of Science in communication disorders from the State University of New York College at Fredonia and her Master of Arts in speech and hearing handicap from the State University of New York College at Geneseo. She has worked in the long-term care and sub-acute setting, but most recently in the acute and outpatient setting with the adult population with the Rochester Regional Health system. She is skilled in objective dysphagia assessments such as modified barium swallow studies (MBSS) and fiberoptic endoscopic evaluation of swallow (FEES). Her areas of focus include dysphagia, cognition, speech and language disorders, a variety of voice disorders including paradoxical vocal fold dysfunction and resonant voice, gastroesophageal reflux disease (GERD) management, and head and neck cancer. Disclosure: Meghan Farrington, MA, CCC-SLP discloses the following potential conflict of interests/commercial interests: Relevant Financial Relationship with Relias LLC as Collecting Speaker's Fees All of the relationships listed for this individual have been mitigated.Relevant Non-Financial Relationship with No Entities Exists as a Contributor All of the relationships listed for this individual have been mitigated.Writer: Susan Almon-Matangos, MS/CCC-SLP
Susan Almon-Matangos, MS/CCC-SLP, is a certified and licensed speech-language pathologist with over 30 years of experience. She obtained her bachelor's degree in psychology from Jacksonville State University and her Master of Science degree in speech-language pathology from The University of Alabama. She worked with clients of all ages and a variety of diagnostic conditions in school, hospital, skilled nursing facility, outpatient clinic, and home health settings. In her previous role as a national clinical director for Aegis Therapies, she created training programs for physical therapy, occupational therapy, and speech-language pathology related to the clinical rehabilitation needs of older adults in post-acute care. She currently draws upon her expertise in her role at Relias as Lead Subject Matter Expert Writer for Speech-Language Pathology. She is a certified member of the American Speech-Language-Hearing Association and the Pennsylvania Speech-Language-Hearing Association. Disclosure: Susan Almon-Matangos, MS/CCC-SLP discloses the following potential conflict of interests/commercial interests: Relevant Financial Relationship with Relias LLC as a Salaried Employee All of the relationships listed for this individual have been mitigated.Relevant Non-Financial Relationship with No Entities Exists as a Contributor All of the relationships listed for this individual have been mitigated.
The target audience for this course is: Intermediate level Speech and Language Pathologists; in the following settings: Acute Care Facility.
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
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All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
If you require special accommodations to complete this module, please contact Relias Customer Support here.
