Table of Contents

Introduction Section I Basics of Documentation Chapter 1 Basic Rules of Documentation Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Chapter 2 Reasons for Documenting Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Chapter 3 Forms and Formats Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Chapter 4 Coding, Reimbursement, and Documentation Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Chapter 5 Focus on Function and Outcomes Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Section II Documenting Dif­fer­ent Types of Services Chapter 6 Evaluation Reports Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Chapter 7 Treatment Plans/Certifications Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Chapter 8 Progress Notes Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Chapter 9 Discharge Summaries and Maintenance Programs Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Section III Documentation and Reimbursement in Adult Health Care Settings Chapter 10 Acute Care: Adult Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Chapter 11 Inpatient Rehabilitation Facility Lynne C. Brady Wagner, MA, CCC-­SLP; Denise M. Ambrosi, MS, CCC-­SLP; and Daniel Meninger, MSPT Chapter 12 Skilled Nursing Facility Renee Kinder, MS, CCC-­SLP, RAC-­CT Chapter 13 Home HealthRebecca Skrine, MS, CCC-­SLP, CHCE, COS-­C Chapter 14 Outpatient Settings: Adul Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Section IV Documentation and Reimbursement in Pediatric Settings Chapter 15 Early Intervention (0 to 3 Years) Karyn Lewis Searcy, MA, CCC-­SLP Chapter 16 School Settings Barbara J. Moore, EdD, CCC-­SLP, BCS-­CL Chapter 17 Outpatient Settings: Pediatric Nancy B. Swigert, MA, CCC-­SLP, BCS-­S Section V Professional Writing and Presentations Chapter 18 Written Communication and Presentations Nancy B. Swigert, MA, CCC-­SLP, BCS-­SGlossaryAbbreviationsFinancial Disclosures Index

About the Author

Nancy B. Swigert, MA, CCC-SLP, BCS­S, speech­language pathologist, is the former director of Speech­Language Pathology and Respiratory Care at Baptist Health Lexington, an acute care facility in Lexington, Kentucky. Prior to that, her private practice, Swigert & Associates, Inc., provided services to children and adults for 26 years. In 2016-2017 she served as the Pro­cess Excellence Coordinator and a Certified Green Belt in Lean/Six Sigma in the Quality Outcomes Department at Baptist, where she coached teams to use data and Lean/Six Sigma pro­cess improvement methodologies. As president of Swigert & Associates., Inc., now a consulting com­pany, she continues to teach and write in the areas of dysphagia, coding and reimbursement, and documentation.

Her main clinical interests are in the areas of pediatric and adult dysphagia. She has authored seven publications with Pro­Ed (Linguisystems): The Source for Dysphagia (4th Edition), The Source for Dysarthria (2nd Edition), The Source for Pediatric Dysphagia (2nd Edition), The Source for Reading Fluency, The Source for Early Intervention, The Source for ­Children’s Voice Disorders, and Reading Fluency and Comprehension. She lectures extensively in the areas of dysphagia and motor speech disorders. She has authored numerous book chapters and articles focusing on documentation and reimbursement.

She received her master’s degree from the University of Tennessee—Knoxville. She is a former President of the Kentucky Speech­Language­Hearing Association and the Council of State Association Presidents. She was President of the American Speech-Language-Hearing Foundation in 2004-2005. She chaired the American Board of Swallowing and Swallowing Disorders from 2012-2014.

She has served in numerous volunteer capacities for the American Speech­Language-Hearing Association (ASHA). In the mid-1990s, she co-chaired the ASHA Task Force on Treatment Outcomes, which initially developed the National Outcomes Mea­sure­ment System (NOMS). She served on the Health Care Economics Committee for 9 years and chaired it for 6. It was during that tenure that she gained invaluable knowledge about reimbursement and documentation requirements. She served on the ASHA Executive Board for 6 years, 3 as Vice ­President for Governmental and Social Policies and then as President-­Elect, President (1998), and Past President. She is an ASHA Fellow and received the Honors of ASHA in 2015.