The Robert F. Pierce Speech-Language-Hearing Clinic
Interns are responsible for maintaining thier clients' clinic records. Clinic Instructors are responsible supervising their interns' maintenance of clinic records. The clinic secretary files documents and sends out information and requests for information.
| Forms at the start of service |
| FORM |
PURPOSE |
PROCESS |
DUE |
| Client Initial Intake Form (Word Document) |
Used to collect basic referral information. This goes in the chart once a person becomes an active client. |
Form may be completed by any RFP intern or staff, or by potential client or referral source.
Secretary keeps forms on file for scheduling. |
Before first scheduled appointment for a new client |
| Clinic Schedule (In Office) |
Record of all clients receiving therapy at RFP Clinic for the semester. This is an office document and not a part of the client's chart. |
Intern completes information on this form, located in the File Room (156A). |
Immediately after scheduling the client; after first session, and after last session for each semester |
| Diagnostic Schedule (In Office) |
This form is used to schedule evaluations through the RFP Clinic. This is an office document and not a part of the client's chart. |
Interns can refer to this schedule to see when they are assigned an evaluation.
Clinic director assigns students to eval teams.
Secretary schedules the appointments. |
As referral for evaluation comes in, it is assigned |
| Policies and Terms of Service (Word Document) |
Outlines the clinic policies and terms of service for prospective clients. This is a client information document and is not a part of the client's chart. |
Interns should be familiar with the information in these documents.
Secretary provides form to client before first session. |
Client's first session of each semester |
| Client Informed Consent for Services (Word Document) |
Client signs this form consenting to the terms of service at RFP Clinic. This is part of the client chart. |
Secretary provides form to client before first session. Client must sign and return form to secretary before first session. |
Client's first session of each semester |
| Client Notice of Notice of Privacy Practices Form (Word Document) |
Client signs this form indicating they have received information about privacy practices and contacts for RFP Clinic. This is part of the client chart. |
Secretary provides form to client before first session. Client must sign and return form to secretary before first session. |
Client's first session of each semester |
| Payment Agreement (In Office) |
Client signs form indicating their plan for paying the Program Access Fee. This is part of the client chart. |
Secretary provides form to client before first session. Client completes and returns form to the secretary. |
Client's first session or third week of services for each semester |
| Notice of Fee Support Program (In Office) |
Client information about the Program Access Fee Support |
Secretary provides information at client request. |
Client's first session for each semester |
| Application for Program Fee Support (In Office) |
Client may use form to apply for fee support by the program deadline. If a client applies, this becomes part of the client chart. |
Client requests form from clinic secretary, completes form and returns it to secretary. |
Client's first session or second week of services for each semester |
| Client Enrollment Information (Word Document) |
Form contains pertinent safety and preference information about client. This is part of the client chart. |
Intern reviews and updates the form with the client.
A new form is generated each Fall semester or the first semester of services.
Secretary files the form. For returning clients in the spring and summer, the |
First session for each semester |
| Service Summary Sheet (Word Document) |
Running log of services to include starting and ending service dates, release and acquisition of records, staffings, phone calls. This is part of the client chart. |
Intern, secretary, and instructors write in log all data pertinent to client case management.
Entries should be in black ink, with no spaces between entries. Entries should be signed and dated. |
Throughout semester of services |
| Observation Informed Consent (In Office) |
This form gives information on the observation policies of the clinic allows the client to give consent to select observers of their sessions. This is part of the client chart. |
Intern and instructors ensure only approved observers access the cleint's sessions.
Secretary provides form to client before first session and files the forms. Client must sign and return form to intern. |
Client's first session for each semester |
| Consent to Photograph for Professional Presentations and Public Relations |
With this form, a client can give permission for specific private health information to be released for specified purposes, such as publich relations or public presentations. If a client agrees to participate, the form becomes a part of the client's chart. |
Intern or instructor will provide the form to the client as appropriate.
If the client agrees, they will sign the form and return it to the secretary.
The secretary files the form in the client's chart. |
As appropriate, before any private information is released |
Release of Information (ROI)
(In Office) |
With this form, a client gives permission for the RFP Clinic to release or obtain thier records from other parties.This is part of the client chart. |
Intern provides the completed ROIs to the client for signature and gives the signed forms to the clinic secretary.
The secretary sends ROI requests and files the forms in the client's chart.
ROIs expire after one year. A current ROI must be on file before any information can be release or obtained from other providers. All ROIs must remain permanently on file. A client must sign a separate ROI for each party with whom information will be exchanged. |
As appropriate, before any private information is obtained or released |
| Case History Forms |
A variety of forms used to gather pertinent information related to a client's communication impairment. This is part of the client chart. |
The secretary mails the form out to individuals who wish to be scheduled for an assessment. When the individual returns the completed paperwork, the secretary schedules them for an assessment. |
As appropriate |
| Client Reports |
| Semester Treatment Plan (template in Computer Lab) |
For clients receiving individual services, the plan outlines the semester objectives. The most recent plan is kept in the client's chart. |
Intern writes the plan in conjunction with the instructor.
The secretary files the plan in the client's chart. |
Generally due the second week of services each semester; varies with client |
| Diagnostic Assessment Report (Word Document) |
Diagnostic assessment teams use this template. This is part of the client chart. |
Intern completes the plan which is approved by the clinic instructor.
If report is to be mailed out, Intern attaches addresses the report and turns it in to the clinic office. Intern ensures current ROIs are in place. |
Generally two weeks after the assessment; interns should consult with their instructor |
| AAC Clinic Assessment Report (template in Computer Lab) |
AAC Clinic Outreach teams use this template for their assessment. This is part of the client chart. |
Intern completes the report which is approved by the clinic instructor.
If report is to be mailed out, Intern attaches addresses the report and turns it in to the clinic office. Intern ensures current ROIs are in place. |
Generally two weeks after the assessment; interns should consult with their instructor |
| Interact Report (Word Document) |
Used for the Interact program. IF the program participant is a client of the RFP Clinic, the report becomes part of the client's chart. |
Intern updates the report after each session.
If report is to be mailed out at the end of the program, Intern attaches addresses the report and turns it in to the clinic office. Intern ensures current ROIs are in place.
|
Generally one week after program ends, though interns add information weekly; interns should consult with their instructor |
| Socialize Report (Word Document) |
Used for the Socialize program. IF the program participant is a client of the RFP Clinic, the report becomes part of the client's chart. |
Intern updates the report after each session.
If report is to be mailed out at the end of the program, Intern attaches addresses the report and turns it in to the clinic office. Intern ensures current ROIs are in place. |
Due at the end of the treatment period, though interns update the report weekly; interns should consult with their instructor |
| Hearing Screening Form (Word Document) |
Used for reporting hearing screeningn results. If the client is appropriate to screen, the form becomes part of the client's chart. |
Intern completes the form in INK and turns it into the office for filing.
The secretary files the form in the client's chart.
See the RFP hearing screening protocol in the Clinical Education Handbook. |
As appropriate, preferably at beginning of treatment period. Due on an annual basis for clients who are appropriate to screen. See screening protcol in this handbook. |
| session progress notes (no form) |
Progress notes contain objective and subjective information on client's progress in therapy and outline plans for next sessions. A set of the most current notes is part of the client's chart.
|
Intern keeps progress notes over the course of the semester.
At the end of the semester,once the instructor has approved the notes, Intern provides a hard copy of their client notes to the office for filing.
Format and frequency of progress notes varies between instructors and clients. |
Due at end of treatment period each semester |
| Semester Treatment Summary (Word Document) |
Summary of client progress over the treatment period. All Summaries are a permanent part of the client's chart. |
Intern completes this report, which is approved by the clinic instructor. If report is to be mailed out at the end of the program, Intern attaches addresses the report and turns it in to the "COMPLETED" file in the clinic office. Intern ensures current ROIs are in place.
The secretary distributes and files the report. |
Due near end of treatment period each semester. See course schedule |
| End of Semester Forms |
| Client Services Questionnaire (Word Document) |
With this form, clients provide feedback on the RFP Clinic Program. this form is not a part of the chart. It is for office use. |
Clinic instructors provide this form to clients at the end of the semester. Clients turn this form in to the drop box in the clinic office |
Last week of services each semester |
| Client Assignment Form (Word Document) |
Form is completed for each client being discharged and for each client being referred for services at RFP. This form is not a part of the chart. It is for office use. |
Intern completes this form and turns it in to the clinic office in the files room. |
After last session of the semester with a client |
| Semester treatment Summary (template in Computer Lab) |
(see Client Reports) |
See course schedule; due end of treatment period for each semester |
| Clinic Schedule (In Office) |
(see Forms at start of service) |
Last day of service each semester |
| Avoid Email |
| EMAIL IS not a secure means of communicating with a client or about a client. CSD Students, faculty, and staff should not use email as a means of communicating about a client, and should use email to initiate communication with a client. If a client chooses to communicate via email with faculty, staff, or students in the CSD Department, the University of Minnesota Policy on email correspondence with patients should be enacted. |
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