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The Oregon Administrative Rules contain OARs filed through June 15, 2014
 
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BOARD OF EXAMINERS FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY

 

DIVISION 10

RECORD KEEPING

 

335-010-0050

Philosophy

Speech-language pathology and audiology professionals in all positions and settings are responsible for maintaining ongoing and complete documentation of the clinical services they provide. Record keeping creates and maintains a record of events pertaining to each client. Clear and comprehensive record keeping facilitates communication between care or treatment providers and interdisciplinary team members, protects both clients and providers, justifies the need for treatment, and documents the results of treatment.

Stat. Auth.: ORS 681.420(5), 681.460
Stat. Implemented: ORS 681.420
Hist.: SPA 2-2004, f. & cert. ef. 5-26-04

335-010-0060

Persons Responsible for Documentation

(1) A licensed speech-language pathology or audiology professional must sign each clinical document or clinical entry with their name and professional title. An electronic record must have an electronic signature. Stamped identification accompanied by an initial or signature is acceptable.

(2) The documentor must be:

(a) The licensed speech-language or audiology professional who directly renders the assessment, care, or treatment; or

(b) In supervision of non-licensed personnel, the speech-language or audiology professional who supervises the assessment, care, or treatment rendered by non-licensed personnel, shall co-sign for those services with their name and professional titles;

(c) In supervision of SLP assistants, refer to OAR 335-095-0050.

(3) The documentation may not be delegated except in emergency situations.

Stat. Auth.: ORS 681.420(5) & 681.460 
Stat. Implemented: ORS 681.420 
Hist.: SPA 2-2004, f. & cert. ef. 5-26-04; SPA 4-2006, f. & cert. ef. 11-3-06; SPA 1-2007, f. & cert. ef. 2-1-07

335-010-0070

General Requirements for Record Keeping and Documentation

(1) Record keeping must conform and adhere to Federal, state, and local laws and regulations.

(2) Records must record history taken; procedures performed and tests administered; results obtained; conclusions and recommendations made. Documentation may be in the form of a "SOAP" (Subjective Objective Assessment Plan) note, or equivalent.

(3) Records and documentation must:

(a) Be accurate, complete, and legible;

(b) Be printed, typed or written in ink;

(c) Include the documentor's name and professional titles;

(d) Stamped identification must be accompanied by initial or signature written in ink.

(4) Corrections to entries must be recorded by:

(a) Crossing out the entry with a single line which does not obliterate the original entry, or amending the electronic record in a way that preserves the original entry; and

(b) Dating and initialing the correction.

(5) Documentation of clinical activities may be supplemented by the use of flowsheets or checklists, however, these do not substitute for or replace detailed documentation of assessments and interventions.

Stat. Auth.: ORS 681.420(5) & 681.460 
Stat. Implemented: ORS 681.420 
Hist.: SPA 2-2004, f. & cert. ef. 5-26-04; SPA 4-2006, f. & cert. ef. 11-3-06; SPA 1-07, f. & cert. ef. 2-1-07

335-010-0080

Storage, Maintenance, and Retention of Records

(1) Clinical and billing records must be maintained for seven (7) years.

(2) All records, including clinical records, must be stored and maintained so that the records are safeguarded, readily retrievable, and open to inspection by the representatives of the Board of Examiners for Speech-Language Pathology and Audiology.

Stat. Auth.: ORS 681.420(5), 681.460
Stat. Implemented: ORS 681.420
Hist.: SPA 2-2004, f. & cert. ef. 5-26-04

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