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I keep a separate record for each client.
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I obtain and record informed consent for all services provided.
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My entries are legible, accurate, and made in chronological order and clearly dated. Any corrections I make to records do not remove the original information.
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I have signed my notes, and initialled any corrections or additions.
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I record sufficient information to allow me or someone else to return to the records at any time and be able to understand what took place and why.
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My entries are made at the time of the session, or as soon thereafter as practicable within 48 hours.
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If I don’t have an opportunity to write my notes until the following day, I always enter the date I’m making the additional entry in the client’s record.
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If documents are scanned to the record, such as external reports, the scanning is done to a sufficient quality that retains the legibility of the original document.
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I have consistent processes for recording the details of any further interactions with clients that may occur via telephone, text message or other method.
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I only use abbreviations that are widely recognised and accepted in speech pathology or I provide a list of abbreviations in the client’s file.
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I don't make subjective or emotive comments; all information is professional. I know that clients have a right to access their records.
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All client care and entries in the record are made with the SPA’s Code of Ethics in mind.
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I keep an appropriate, consistent standard of clinical records for all clients, not just those with complex needs.
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While I may ask a suitably qualified assistant to record some health information in the client’s record, I always review their entries. I know that I cannot delegate responsibility for the accuracy of health information recorded to another person.
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The date of any funding claim matches the date of therapy in the clinical record.
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The claim item number matches the therapy type and length detailed in the clinical record
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The provider number recorded for a claim matches the provider number for the speech pathologist that provided the service according to the clinical record.
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My records are stored securely and in a way that ensures they can be promptly retrieved
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My records are collected, maintained, transferred and disposed of in accordance with privacy laws and state or territory laws.
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I have developed a privacy policy that provides information to clients about the collection, access, disclosure and retention of their health records.
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We have regular training for everyone at our practice about the appropriate collection, storage, access and disposal of records.
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