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If you didn’t document it, you didn’t do it.” Competent professional writing is a necessity, not a luxury. Third-party payers, such as insurance companies, may deny payment if the documentation for professional services is incorrect or incomplete. Medical chart notes, diagnostic evaluations, progress reports, and discharge summaries are all legal documents that may be used in court. The Code of Ethics of the American Speech-Language Hearing Association (ASHA , 2016) states that individuals shall provide all services competently, and that includes documentation of services rendered.
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