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DOCTOR OF AUDIOLOGY (AuD) HANDBOOK FOR CLINICAL PRACTICUM rev. 06/04 Page 1 CONTENTS Page SECTION I OVERALL REQUIREMENTS .............................................................................. 5 Observation Hours ......................................................................................... 5 Clinical Clock Hours ...................................................................................... 5 Clinical Certification Board Interpretations on Clinical Practicum...............…. 5 SECTION II POLICIES AND PROCEDURES ........................................................................... 6 Physical Examination/Immunization ............................................................… 6 Ethical Responsibility ..................................................................................... 6 Professional Responsibility ............................................................................. 7 Professional Liability Insurance ..................................................................... 7 Practicum Assignments .................................................................................. 7 SECTION III ON-CAMPUS CLINIC PROCEDURES ................................................................ 8 Patient Files ................................................................................................... 8 Security ............................................................................………………...... 9 Equipment.....................................................................................…………. 9 Computers.............................................................................………………. 9 Page 2 Release/Clearance Forms…………………………………………………….. 9 Diagnostic Evaluation Report ........................................................................ 10 Information from Outside Agencies ............................................................... 10 Financial Record ............................................................................................. 10 SECTION IV STUDENT PRACTICUM FORMS ......................................................................... 11 Practicum Paperwork Deadlines……………………………………………….. 11 Practicum Commitment Form .......................................................................... 11 Audiology Clinical Experience Record Form ...............................................…. 11 Self-Evaluation ............................................................................................… 12 AuD Student Evaluation of Site and Preceptor ..........................................…. 12 AuD Skills Competency Evaluation Form ........................................................ 12 Record of Observation Experience ...............................................................… 12 SECTION V CERTIFICATION AND LICENSURE .................................................................. 13 Certification of Clinical Competence ..........................................................…. 13 Board Certification by the American Board of Audiology……………………. 13 Ohio Licensure for Audiology ....................................................................… 13 Educational Audiology Certification…………………………………………. 13 Page 3 SECTION VI PROFESSIONAL ORGANIZATIONS ............................................................. 14 APPENDICES Appendix A: Student Practicum Forms…………………………………. 15 Practicum Commitment Audiology Clinical Experience Record (Hours) AuD Student Evaluation of Site and Preceptor AuD Skills Competency Evaluation Observation Report Record of Observation Experience Confidentiality Statement Appendix B: Client Forms………………………………………………. 29 Client Information Sheet Notice of Health Information Privacy Practices Acknowledgement of Notice Form Audiologic Case History – Adult Audiologic Case History – Pediatric Sample Format for Evaluation Report Release/Clearance Form Hearing Aid Purchase Agreement Professional Services Documentation Form Financial Record Form Appendix C: Code of Ethics……………………………………………… 42 American Academy of Audiology American Speech-Language-Hearing Association Director, Woodward Hearing, Speech, John Greer Clark, Ph.D. and Language Clinic & Clinical Supervisor CCC/A-SLP Assistant Professor CSD Audiology Practicum Coordinator Janet A. Stein, M.A., & Clinical Supervisor CCC/A Assistant Clinical Professor Page 4 SECTION I OVERALL REQUIREMENTS Clinical practicum experiences are provided for graduate students in the University of Cincinnati Audiology Clinics on East Campus and at the Woodward Career Technical High School as well as off-campus sites. Graduate students gain experience with children and adults with a variety of auditory problems in a wide range of settings. OBSERVATION HOURS The Communication Sciences and Disorders Department requires that students observe a minimum of 25 hours of evaluation and treatment of children and adults with disorders of speech, language and/or hearing prior to participating in clinical practicum. These observations must be supervised by a person holding the Certificate of Clinical Competence (CCC) in the area being observed. CLINICAL CLOCK HOURS Students must obtain a minimum of 2,000 clinical clock hours in order to graduate with the AuD degree as well as fulfill ASHA requirements for certification. For audiology licensure in the state of Ohio, a student currently (2004) must have a minimum of 350 clock hours of evaluation/treatment experience (in addition to the 25 observation hours) with a variety of disorders as well as a minimum of 50 hours in at least 3 different clinical sites. The following outlines the minimum clinical clock hours for meeting Ohio licensure requirements: EVALUATION: 80 hours TREATMENT: 20 hours Adults - 40 Children - 40 AMPLIFICATION: 80 hours SPEECH PATHOLOGY: 20 hours Adults - 10 Screening - 20 Children - 10 *with normal hearing persons* The Ohio Board of Speech-Language Pathology and Audiology is working at the present time to change the Ohio audiology licensure requirements to reflect the upgrade to the AuD degree, but until the new mandates are put into effect AuD students will need to fulfill the current requirements. CLINICAL CERTIFICATION BOARD INTERPRETATIONS ON CLINICAL PRACTICUM Persons holding CCC in Audiology may supervise: Audiological evaluation; Amplification (hearing aid selection and management); Aural habilitative and rehabilitative services; Speech and/or language screening for the purpose of initial identification of individuals with other communicative disorders. 5 SECTION II POLICIES AND PROCEDURES IT IS THE RESPONSIBILITY OF THE STUDENT CLINICIAN TO BECOME FAMILIAR WITH AND FOLLOW THE POLICIES AND PROCEDURES IN THIS CLINIC BOOK. Any deviations from these established guidelines must be discussed with and approved by the practicum coordinator and the site preceptor. PHYSICAL EXAMINATION/IMMUNIZATION A physical examination and proof of immunization for measles, mumps, rubella, and 3-step series and titer of hepatitis B is required of each student clinician. A yearly two-step Mantoux tuberculin test is required. Yearly participation is mandatory for blood borne pathogens training. Some training sites may require drug screening, CPR training, and/or criminal background checks. Students should be familiar with clinical infection control procedures (see www.audiology.org for infection control guidelines for audiologists). ETHICAL RESPONSIBILITY Information regarding patients must be held in the strictest confidence. Cases may be discussed with the preceptor, faculty, other professionals, and other student clinicians within the U.C. Department or the practicum site offices; however, patients are not to be discussed with other persons outside these locations. Do not talk about patients in the waiting room, hallways, or anywhere else; conversations could be overheard by individuals not entitled to the information. All students will be asked to sign a Confidentiality Statement at the beginning of their graduate academic program to enforce this responsibility. All student clinicians are expected to perform according to the standards, practices, and guidelines established by both the American Academy of Audiology (AAA) and the American Speech- Language-Hearing Association (ASHA) as described in the associations’ Codes of Ethics. Copies of Code of Ethics statements are provided in Appendix C of this handbook. Students are advised to become familiar with these documents and the licensure laws governing the provision of clinical services. 6 PROFESSIONAL RESPONSIBILITY All students participating in clinical activities are expected to present a professional appearance. Style of dress should reflect the role of a professional. Low cut blouses, blue jeans, shorts, and gym shoes are not considered appropriate clinical dress. Jewelry worn in the clinic should be conservative in nature. Promptness is a professional courtesy that all student clinicians must extend to patients. Clinicians should arrive at the practicum site with enough time before their scheduled appointments to check equipment, set up work areas, speak with the preceptor, etc., to enable them to see their patients promptly at the scheduled time. PROFESSIONAL LIABILITY INSURANCE Students are required to carry professional liability insurance coverage. All students enrolled in the CSD program are covered under UC’s Medical Professional Insurance Program during the time they are enrolled in the CSD program. PRACTICUM ASSIGNMENTS Students must have written documentation of 25 observation hours before practicum can be initiated. The practicum coordinator will assign students to observation sites if needed. Students who have completed all required undergraduate course work and observation hours will be assigned to practicum either in on-campus clinic or at a cooperating off-campus site during the fall quarter of the first year. Typically, first year students will be assigned four to six hours of practicum per week. Students may have one or two different part-time practicum sites during the first year. An assignment also will be made for the summer quarter when increased practicum hours will be expected of the student. The on-campus clinic follows the regular University of Cincinnati academic calendar. Most off- campus facilities operate year round or on a school year schedule that differs from the University schedule. Students are expected to adhere to the schedule of the cooperating facility during their assignment at that site. This means that a University break on campus possibly may not be taken during a two-quarter assignment unless cleared in advance with the site preceptor. 7 SECTION III ON-CAMPUS CLINIC PROCEDURES PATIENT FILES A. Client Information Sheet and File Contents The clinic director or preceptor and responsible party will complete the Client Information Sheet and oversee the compilation of a file including the following items: 1. Client Information Sheet 2. Notice of Health Information Privacy Practices (HIPAA form) 3. Acknowledgement of Notice form 4. Case History form – Adult 5. Case History form – Pediatric 6. Release/Clearance form 7. Hearing Aid Contract form 8. Professional Services Documentation form 9. Financial Record form B. Case Assignment The clinic director or assigned preceptor will give the file to the practicum student. The student will then coordinate the diagnostic/treatment time with the faculty preceptor and the patient. Appointments should be scheduled as soon as possible. C. Confirmation of Appointment A confirmation letter plus a map of the campus, if needed, will be sent to the patient. The student will meet the patient in the clinic area in the East Campus Clinic or at the door near the parking lot at the UC/Woodward clinic. D. Case File The student is responsible for completing and maintaining the case file. The file will remain in the file cabinets in Room G43 on East Campus or in the file at Woodward. The student is responsible for including a copy of the case history diagnostic evaluation report and release forms for each patient assigned seen quarter. Those students under immediate supervision of the assigned preceptor will be responsible for "accessing" and "sending" patient records and reports to other agencies, professionals, etc. Preceptors will assure that proper releases and procedures have been followed. NO CLINIC FILES ARE TO BE REMOVED FROM THE CLINICS. This rule must be strictly enforced to avoid lost or missing folders, resulting in a breach of confidentiality. 8 E. Financial Record Payment of fees for diagnostic evaluations and treatment, including hearing aid fittings, are determined by the Clinic Director or the Practicum Coordinator. All contracts and financial records are included in each patient's file. The white copy of the completed Patient Information Form, the white copy of the Financial Record Form, and any payments must be given to the clinic business office to establish an account. A copy of the Financial Record Form is to be submitted to the clinic business office with each payment thereafter to ensure accurate accounting. The student will check with the clinic business office at the end of the billing cycle to ensure that all payments and/or billings have been completed. SECURITY For security purposes, Audiology Clinics are to be closed and locked when not occupied. Please inform the Clinic Director, Practicum Preceptor, or Practicum Coordinator if a clinic is found open and unattended. EQUIPMENT Students are responsible for cleanliness of clinic work areas. Re-usable clinic supplies that are used in patient evaluation must be cleaned and disinfected or sterilized in accordance with infection control guidelines (see www.audiology.org). All equipment that has been checked out for off-site use must be returned with 24 hours unless prior approval has been granted from the Clinic Director or Practicum Coordinator. COMPUTERS You are responsible for informing your preceptor of any computer problems, technical or content related. Do not install any program onto these computers without approval from Dr. Rick Devan. RELEASE/CLEARANCE FORMS The Health Insurance Portability and Accountability Act (HIPAA) requires signed release forms to be in a patient’s file before the clinic can send out any patient information. If these signed forms are not in a patient’s file, we may not send copies of the patient’s reports to anyone, even if the patient has verbally requested that we do so. Clinicians of on-going patients (i.e.: hearing aid recipients) are advised to check their patients’ folders at the start of the quarter for signed release forms to avoid inadvertently releasing reports without permission. Students must also have a clearance form signed by a patient or parent for photographs, observations, and videotaping (Appendix B). All forms can be obtained from the Clinic Director or Practicum Coordinator when needed. 9 DIAGNOSTIC EVALUATION REPORT Students involved in the assessment of hearing are responsible for writing a diagnostic report which must be submitted to the preceptor within three “business” days of the patient’s appointment. A sample format for the diagnostic report is included in Appendix B. Clinic reports must be written on floppy diskettes in the clinic area on the ground floor. Students are not allowed to write clinic reports on their home computers. Each student will be given a floppy diskette to use for clinic reports, which will be kept in the clinic file drawer with the chart. Do not save file to any computer. Save information only to the assigned diskette. In order to comply with HIPAA regulations, reports on diskettes which include any health information which could identify the patient (name, address, age, social security number, phone, etc) must have those items de-identified. The final printout may include name, address, phone number and placed in the client file. After the preceptor has approved the final report, at the end of the quarter the diskette will be erased and given back to the preceptor. INFORMATION FROM OUTSIDE AGENCIES Physician’s reports, summary reports from other agencies, etc., are to be filed in the patient’s folder. The appropriate form necessary to obtain information from outside agencies is available from the Clinic Director or Practicum Preceptor (Appendix D). 10 SECTION IV STUDENT PRACTICUM FORMS PRACTICUM PAPERWORK DEADLINES The student is responsible for completing the following forms every quarter and adhering to the stated deadlines. These forms are available in the clinical faculty office area (G45). Due the second week of the quarter: Practicum Commitment Due Wednesday of exam week: Clinical Experience Record (practicum hours sheet) Self Evaluation (Narrative) AuD Student Evaluation of Site and Preceptor (except when continuing at the same site the following quarter) Due within 2 weeks after quarter ends: AuD Skills Competency Evaluation form (completed form from preceptor) PRACTICUM COMMITMENT FORM Due the second week of the quarter: At the beginning of the quarter the student and preceptor meet to negotiate and sign the practicum contract. The contract should be given to the Practicum Coordinator by the second week of the quarter. CLINICAL EXPERIENCE RECORD FORM Due Wednesday of Exam week: At the end of the quarter, the student clinician uses the Clinical Experience Record form to complete, in duplicate, a summary of his/her total clinical hours. ONLY ONE FORM IS REQUIRED PER QUARTER. MULTIPLE EXPERIENCES/SITES SHOULD GO ON THE SAME FORM. The student is responsible for filling out the form completely including the quarter, year, dates, and column totals. Both copies are to be signed by the preceptor(s) and the practicum coordinator. One copy is put into the student's practicum file and the second copy is for the student clinician to keep for his/her own records. The Department copy is later entered into the software program in order to track the student’s hours. A printout of total hours to date is given to each student at the end of each quarter. The clinical records are the official record to verify students' clinical hour accumulations toward fulfilling licensure, ASHA, and degree requirements. 11 SELF EVALUATION Due Wednesday of Exam Week: At the end of the quarter, the student clinician will write a narrative self-evaluation. The completed evaluation is to be discussed with the site preceptor and then submitted to the practicum coordinator. AuD STUDENT EVALUATION OF SITE AND PRECEPTOR FORM Due Wednesday of Exam Week: The student must complete a site/preceptor form at the end of the quarter. The student may wait to complete this form until the end of a two-quarter or more practicum assignment at the same site. The form is given to the university Practicum Coordinator, who will forward it to the Preceptor after it is reviewed. AuD SKILLS COMPETENCY EVALUATION FORM (from Preceptor) Due within 2 weeks after quarter ends: At the end of every quarter, the site preceptor will complete an evaluation of the student’s performance. The student is responsible for bringing a U. C. Practicum Evaluation Form to the preceptor at the end of the quarter. The preceptor may use this form and additionally any other evaluation form of their choosing. The student and preceptor should discuss their evaluations at the end of the quarter. The preceptor will forward the evaluation to the Practicum Coordinator within two weeks after the quarter ends. The Practicum Coordinator will review the evaluation and place it in the student’s file. RECORD OF OBSERVATION EXPERIENCE All observation clock hours accumulated by the student clinician are to be recorded, in duplicate, on the Clinical Observation Form. Both copies are to be signed by the preceptor. One copy is to be given to the practicum coordinator and the second copy is for the student clinician's records. An Observation Report form must be completed for each time period in which the student is involved in observation activities. 12 SECTION V CERTIFICATION AND LICENSURE CERTIFICATE OF CLINICAL COMPETENCE ASHA's Certificate of Clinical Competence can be obtained by individuals who meet specific requirements in academic and clinical preparation. A minimum of 2,000 clinical clock hours are required for ASHA certification. Students also must pass the national examination in audiology, a Specialty Area Test of The Praxis Series by the Educational Testing Service (ETS). BOARD CERTIFICATION BY THE AMERICAN BOARD OF AUDIOLOGY American Board of Audiology certification is a voluntary, nationally recognized standard that is not tied to membership in any professional organization. Audiologists certified by the ABA must hold an academic degree in audiology, have passed a national examination, and have demonstrated that they have completed a minimum of 2000 hours of mentored professional practice in a two-year period. The mentor must be a state licensed or ABA certified audiologist. Certification is valid for a period of three years renewable upon demonstration of meeting continuing education requirements. Provisional certification is available for students in the third year of their audiology doctorate program. OHIO LICENSURE IN AUDIOLOGY Audiology licensing by the Ohio Board of Speech Pathology and Audiology can be obtained by individuals who have met specific requirements in academic and clinical preparation and have successfully passed the national examination in audiology, a Specialty Area Test of The Praxis Series by the Educational Testing Service (ETS). Refer to the “Overall Requirements” section of this handbook under “Clinical Hours” for specific requirements. An application for licensure can be obtained by writing to: Ohio Board of Speech Pathology and Audiology, 77 South High St., 16th Floor, Columbus, OH 43215 or call (614) 466-3145. EDUCATIONAL AUDIOLOGY CERTIFICATION A State of Ohio professional pupil services license as an educational audiologist can be obtained by completing necessary coursework and obtaining practicum experience in the schools. Contact the Audiology Practicum Coordinator or Student Teaching Coordinator for more information about these requirements. 13 SECTION VI PROFESSIONAL ORGANIZATIONS All student clinicians are encouraged to apply for membership in the National Association of Future Doctors of Audiology (NAFDA). NAFDA is a professional student organization dedicated to the advancement of education and technological training in the profession of Audiology with emphasis on enhanced patient care. The organization takes pride in being of, by, and for individuals dedicated to promoting audiology as a doctoral level profession. The University of Cincinnati has an active NAFDA Chapter. In addition students are encouraged to apply for student membership in the following organizations: National Student Speech-Language-Hearing Association (NSSLHA) The Ohio Speech and Hearing Association (OSLHA) Southwest Ohio Speech, Language, and Hearing Association (SWOSHA) Student membership is inexpensive and includes most of the benefits of full membership including journals, newsletters, and reduced fees for workshops and conventions. Membership applications are available in the Department. 14 APPENDIX A STUDENT PRACTICUM FORMS 15 PRACTICUM COMMITMENT University of Cincinnati Communication Sciences and Disorders Department Student: ________________________________________________________ Quarter/Year:____________________________________________________ Site: ____________________________________________________________ The University of Cincinnati student who has been assigned to a Communication Sciences and Disorders Practicum has agreed to the following guidelines: 1. The student will begin the practicum experience on__________and finish on____________. Days per week: (circle) M T W TH F 2. The student will maintain the following hours:__________________________ 3. The student is allowed______________off days. 4. The student will follow all rules of confidentiality as they pertain to clients and clients’ families. 5. Therapy plans, evaluations, and other reports must be submitted by deadlines specified by the site preceptor: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 6. The student will participate in at least_________________of directed observation before he/she begins to provide clinical services (up to a maximum of____________). 7. The student will comply with all policies and procedures of the practicum site: _____________________________________________________________________ _____________________________________________________________________ It is understood that the practicum experience may be terminated at any time during the first ____ week trial period either by the site preceptor, Practicum Coordinator, or the student. It is further understood that the practicum experience may be terminated at any time at the discretion of the site preceptor and/or Practicum Coordinator. 16 Practicum Commitment Page 2 of 2 The on-site preceptor has agreed to the following guidelines: 1. The preceptor will have primary responsibility for coordination and supervision of the student’s professional work at this site. 2. The preceptor recognizes and agrees to abide by the observation requirements set by ASHA: supervision of a minimum of one-forth of therapy time and one-half of diagnostic time. 3. The preceptor and student will have conferences scheduled at least_______________ _____________________________________________________________________. 4. The preceptor will share the evaluation of the student’s performance with the student and Practicum Coordinator. The Practicum Coordinator will make____visit(s) to the practicum site during the quarter. ______________________________________________________ Student ______________________________________________________ Site Preceptor ASHA# State License# ______________________________________________________ U.C. Practicum Coordinator 17 18 19 UNIVERSITY OF CINCINNATI COMMUNICATION SCIENCES AND DISORDERS DEPARTMENT AuD STUDENT EVALUATION OF SITE AND PRECEPTOR Student: ________________________________ Quarter(s):_______________ Year:______ Site: ___________________________________ Address: _______________________________ City:_____________ State:____ Zip:_____ Phone:_________________________________ Preceptor: ASHA#: State License#:_______ 1. What percentage of the time were you directly supervised when performing clinical activities? 2. Did the preceptor inform you of expected student clinical competencies for this setting? If so, was this done verbally and/or in writing? 3. Were guidelines provided to you for writing reports (if applicable)? In what manner did the preceptor provide these to you? 4. Regarding clinic workload, do you feel that you were given (circle one or more): a) too many patients b) too few patients c) not enough variety of patients d) appropriate number and variety of patients Comments: 20 5. In what form did you receive feedback from your preceptor? When did this occur? 6. Did you feel free to ask questions and/or voice concerns to your preceptor? Explain. 7. Did the preceptor make an effort to arrange conferences with you? How often? 8. On a scale of 1 to 10, how would you rate this practicum experience? Why? 9. What would you change about this practicum experience if you could? 21 AuD Skills Competency Evaluation Student: _________________________________ Skills Assessment Detail The competency statements that comprise this document have been designed for the purpose of practicum goal- setting and the monitoring and evaluating of students’ clinical performance. The organizational structure is designed to enable our program to determine if and when a student has mastered the specific skill competencies identified on our certification standards. The specific competency statements from the standards that the student is required to master and are addressed with this evaluation form are shown on the last page of this packet. The competencies are categorized into four skill areas: Specific Evaluation Skills, Specific Treatment Skills, General Clinical Skills, and Professional Skills. The following table displays the desired performance rubric to use in evaluating students’ clinical performance Use the scale numbers to indicate the students level of performance for the competencies appropriate to the particular clinical experience. It is not anticipated that each of the listed competencies on the form will be evaluated for each clinical experience. Enter a performance level value only for those specific skill competencies the student demonstrated in this clinical experience. Leave the other skill competencies blank. Comments can be entered for each specific skill category. Performance Rubric 1. Not Evident Competency/skill not evident; Requires constant preceptor modeling/intervention 2. Emerging Competency/skill emerging; Requires frequent preceptor instruction 3. Developing Competency/skill present but needs further development; Requires frequent preceptor monitoring 4. Refining Competency/skill developed but needs refinement and/or consistency; Requires infrequent preceptor monitoring 5. Independent Competency/skill well-developed and consistent; Requires guidance and/or consultation only 22 AuD Skills Competency Evaluation Student: ___________________ Preceptor:________________________ Date:____________ Quarter:________ Site:______________________________ Evaluation 23 AuD Skills Competency Evaluation 24 AuD Skills Competency Evaluation CCC Competency Standards Standard IV-C. Prevention and Standard IV-D. Evaluation. The applicant Standard IV-E. Treatment. The applicant Identification. The applicant must be must be competent in the evaluation of must be competent in the treatment of competent in the prevention and individuals with suspected disorders of individuals with auditory, balance, and identification of auditory and vestibular auditory, balance, communication, and related communication disorders. At a disorders. At a minimum, applicants related systems. At a minimum, applicants minimum, applicants must have the must have the knowledge and skills must have the knowledge and skills knowledge and skills necessary to: necessary to: necessary to: C1. Interact effectively with patients, families, D1. Interact effectively with patients, families, E1. Interact effectively with patients, families, other appropriate individuals and professionals. other appropriate individuals and professionals. other appropriate individuals, and professionals. C2. Prevent the onset and minimize the D2. Evaluate information from appropriate E2. Develop and implement treatment plan using development of communication disorders. sources to facilitate assessment planning. appropriate data. C3. Identify individuals at risk for hearing D3. Obtain a case history. E3. Discuss prognosis and treatment options with impairment. D4. Perform an otoscopic examination. appropriate individuals. C4. Screen individuals for hearing impairment D5. Determine the need for cerumen removal. E4. Counsel patients, families, and other and disability/handicap using clinically appropriate individuals. D6. Administer clinically appropriate and appropriate and culturally sensitive screening E5. Develop culturally sensitive and age culturally sensitive assessment measures. measures. appropriate management strategies. D7. Perform audiologic assessment using C5. Screen individuals for speech and language E6. Collaborate with other service providers in physiologic, psychophysical, and self-assessment impairments and other factors affecting case coordination. measures. communication function using clinically D8. Perform electrodiagnostic test procedures. E7. Perform hearing aid, assistive listening appropriate and culturally sensitive screening device, and sensory aid assessment. measures. D9. Perform balance system assessment and determine the need for balance rehabilitation. E8. Recommend, dispense, and service prosthetic C6. Administer conservation programs designed and assistive devices. to reduce the effects of noise exposure and of D10. Perform aural rehabilitation assessment. agents that are toxic to the auditory and vestibular E9. Provide hearing aid, assistive listening D11. Document evaluation procedures and systems. device, and sensory aid orientation. results. E10. Conduct aural rehabilitation. D12. Interpret results of the evaluation to establish type and severity of disorder. E11. Monitor and summarize treatment progress and outcomes. D13. Generate recommendations and referrals resulting from the evaluation process. E12. Assess efficacy of interventions for auditory and balance disorders. D14. Provide counseling to facilitate understanding of the auditory or balance disorder. E13. Establish treatment admission and discharge criteria. D15. Maintain records in a manner consistent with legal and professional standards. E14. Serve as an advocate for patients, families, D16. Communicate results and recommendations and other appropriate individuals. orally and in writing to the patient and other E15. Document treatment procedures and results. appropriate individual(s). E16. Maintain records in a manner consistent D17. Use instrumentation according to with legal and professional standards. manufacturer's specifications and E17. Communicate results, recommendations, recommendations. and progress to appropriate individual(s). D18. Determine whether instrumentation is in E18. Use instrumentation according to calibration according to accepted standards. manufacturer's specifications and recommendations. E19. Determine whether instrumentation is calibration according to accepted standards. 25 UNIVERSITY OF CINCINNATI DEPARTMENT OF COMMUNICATION SCIENCES AND DISORDERS OBSERVATION REPORT Name of Observer_________________________________________________________ Location________________________________________________________________ Date of Observation___________________________Duration of Session____________ Individual______________________________Group____________________________ Diagnostic Evaluation______________________________________________________ Treatment Session__________________________________________________________ Type of Hearing Loss_____________________________________________ General Objective_________________________________________________________ Describe methods and materials used__________________________________________ ________________________________________________________________________ ________________________________________________________________________ Summarize the way the patient responded to the visit____________________________ ________________________________________________________________________ ________________________________________________________________________ Comments_______________________________________________________________ ________________________________________________________________________ Signature of clinician, preceptor, or class instructor ________________________________________________________________________ 26 RECORD OF OBSERVATION EXPERIENCE Name__________________________ Quarter _____________________ Year _______ Date Clinician/Sit Child / Type of Hearing Eval. Or Amt. Of Preceptor’s e Adult Disorder Treatment Observ. Signature Time 27 Department of Communication Sciences and Disorders College of Allied Health Sciences University of Cincinnati Medical Center PO Box 670379 Cincinnati, OH 45267-0379 202 Goodman Drive 344 French East Building Phone (513) 558-8501 Fax (513) 558-8500 CONFIDENTIALITY STATEMENT All information concerning past and present patients is strictly confidential and will be shared with no one unless agreed upon in writing by the patient or patient’s family. I understand the importance of confidentiality as it relates to the welfare of patients and their families whom we serve. I will not reveal any professional or personal information regarding these patients and I will maintain accurate information in the patient’s clinical files and will not divulge the contents of such files to anyone except upon written consent from the patient or the family. I understand and agree to abide by the confidentiality standards set by the Department of Communication Sciences and Disorders. ______________________________ ___________________ Signature of Student Clinician Date _____________________________ Printed Name of Student Clinician 28 APPENDIX B CLIENT FORMS 29 CLIENT INFORMATION SHEET UC Speech & Hearing Clinic G65 French East Building/P.O. Box 670394 Cincinnati, OH 45267-0394 513-558-8502 DATE____________ A. TO BE FILLED OUT COMPLETELY BY RESPONSIBLE PARTY Client Name______________________________ DOB_____________ Age_______ Parent/Responsible Party_______________________________SS#______________ Home Address_________________________________________________________ City_________________ State ____ Zip____ Area Code/Phone Number__________ Non-UC-affiliated clients: Client (parent) employer ________________________________________________ Address______________________________city/state/zip______________________ Work phone #_________________________ Current insurance coverage: yes _______ no _________ Group name/health plan______________________________________________ Address___________________________________________________________ Phone #__________________ Group or member # ________________________ UC-affiliated clients: Employee_______faculty_________staff__________student__________ Department name_____________________________________College________ Department phone #________________ ML #______________ Student________ grade/yr__________________________ Full-time____Part-time____ Employed: yes____ no_____ Employer_______________________________________ Address________________________________________ _______________________________________________ Work phone #___________________________________ Please make check or money order payable to: University of Cincinnati B. TO BE FILLED OUT COMPLETELY BY CLINIC DIRECTOR Evaluation Date___________________ First Therapy Session Start Date__________ Grad Student Clinician______________ Preceptor___________________________ Eval. Fee $ ________ Session fee $___________ Payment schedule ______weekly_________monthly (NO QUARTERLY BILLINGS PERMITTED) Clinicians must immediately turn in completed Client Information Sheet intact to Clinic Director. 30 NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS IFORMATION. PLEASE REVIEW IT CARELFULLY. The Audiology Clinic is required to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices. The Audiology Clinic will not use or disclose your health information except as described in this notice. This notice applies to all of the medical records generated by the Audiology Clinic as well as records we receive from other providers. USE AND DISCOLOSURES REQUIRING YOUR CONSENT: With your consent, the Audiology Clinic may use and disclose your health information for the following purposes. TREATMENT: The Audiology Clinic may use your health information in the provision and coordination of your healthcare. We may disclose all or any portion of your medical record information to your attending physician, consulting physician(s), nurses, technicians, medical students, and other health care providers who have a legitimate need for such information in your care and treatment. Different entities may share health information about you in order to coordinate specific services such as prescriptions, lab work, and x-rays. The Audiology Clinic also may disclose your health information to people outside the Audiology Clinic who may be involved in your medical care after you leave the Audiology Clinic such as family members, clergy and others used to provide services that are part of your care. Other ways we may use or disclose your health information for purposes related to treatment are: Treatment Alternatives: To tell you about or recommend possible treatment options or alternatives that may be of interest to you. Appointment Reminders: To contact you as a reminder that you have an appointment for treatment at the Audiology Clinic. PAYMENT: The Audiology Clinic may release health information about you for the purposes of determining coverage, billing, claims management, medical data processing, and reimbursement. The information may be released to an insurance company, third party payer or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record which are necessary for payment of your account. For example, a bill sent to a third party payer may include information that identifies you, your diagnosis, and the procedures and supplies used. We may also provide payment information to other care providers who have been involved in your care, e.g., an ambulance company. ROUTINE HEALTHCARE OPERATIONS: The Audiology Clinic may use and disclose your health information during routine healthcare operations, including quality assurance, utilization review, medical review, internal auditing, accreditation, certification, licensing or credentialing activities of the Audiology Clinic, medical/audiologic research and educational purposes. The Audiology Clinic may engage outside companies to carry out certain aspects of routine healthcare operations. These entities are called the “business associates” of the Audiology Clinic. The Audiology Clinic may need to disclose your health information to the business associates to allow them to perform their duties. The business associates will, in turn, use and disclose your health information as they conduct business on behalf of The Audiology Clinic. Examples of business associates include, but are not limited to, a copy service to copy medical records, consultants, accountants, lawyers, medical transcriptionists, and third-party billing companies. The Audiology Clinic 31 requires the business associates to protect the confidentiality of your health information. USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION: The Audiology Clinic may not disclose your health information to persons outside of the Audiology Clinic for purposes other than treatment, payment, or healthcare operations without your authorization. You have a right to revoke any authorization you have previously given by submitting a written statement of revocation to the Audiology Clinic. USES AND DISCLOSURES TO WHICH YOU MAY OBJECT: FAMILY FRIENDS: The Audiology Clinic may disclose your health information to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell these persons of your condition. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you have any objection to the use and disclosure of your health information in this manner, please tell us. USES/ DISCLOSURES THAT ARE REQUIRED OR PERMITTED WITHOUT CONSENT OR AUTHORIZATION RESEARCH: Under certain circumstances, the Audiology Clinic may use and disclose your health information to approved clinical research studies. While most clinical research studies require specific patient consent, there are some instances in which a retrospective record review with no patient contact may be conducted by such researchers. Personal identification would be removed from subsequent reporting of data. REGULATORY AGENCIES: The Audiology Clinic may disclose your health information to government and certain private health oversight agencies, e.g., the Department of Public Health and Environment, the Joint Commission on Accreditation of Healthcare Organization, the Board of Speech-Language-Pathology and Audiology or the Board of Medical Examiners for activities authorized by law including, but not limited to, licensure, certification, audits, investigations and inspections. These activities are necessary to monitor compliance with the requirements of government programs. LAW ENFORCEMENT/LITIGATION: The Audiology Clinic may disclose your health information for law enforcement purposes as required by law or in response to court order. PUBLIC HEALTH: The Audiology Clinic may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability. WORKER’S COMPENSATION: The Audiology Clinic may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. MILITARY/VETERANS: The Audiology Clinic may disclose your health information as required by military command authorities if you are a member of the armed forces. AS OTHERWISE REQUIRED BY LAW: The Audiology Clinic will disclose your health information in any situation in which such disclosure is required by law (e.g., child abuse, domestic abuse). YOUR RIGHTS RELATED TO YOUR HEALTH INFORMATION: Although all records concerning your treatment obtained at the Audiology Clinic are the property of the Audiology Clinic you have the following rights concerning your health information. RIGH TO CONFIDENTIAL COMMUNICATIONS: You have a right to receive confidential communication of your health information by alternate means or at alternate locations. For example, you may request that we only contact you at work or by mail. RIGHT TO INSPECT AND COPY: You generally have a right to inspect and copy your health information except as restricted by law. 32 RIGHT TO AMEND: You have the right to request an amendment or correction to your health information. If we agree that an amendment or correction is appropriate, we will ensure that the amendment or correction is attached to your medical record. RIGHT TO AN ACCOUNTING: You have the right to obtain a statement of the disclosures that have been made of your health information other than by your authorization, other than to you and other than for the purpose of treatment, payment or routine operational purposes. RIGHT TO REQUEST RESTRICTIONS: You have the right to request restrictions on certain uses and disclosures or your health information. If we are able to agree to your request, we will abide by the restrictions. RIGHT TO RECEIVE COPY OF THIS NOTICE: You have the right to receive a paper copy of this Notice, upon request, if this Notice has been provided to you electronically. RIGHT TO REVOKE CONSENT OR AUTHORIZATION: You have the right to revoke your consent or authorization to use or disclose your health information, except to the extent that action has already been taken in reliance on your consent or authorization. IF YOU BELIEVE THAT YOUR RIGHTS HAVE BEEN VIOLOATED: You may file a complaint with the Audiology Clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with the Audiology Clinic please contact us at 513-422-6516. All complaints must be submitted in writing. There will be no retaliation for filing a complaint. CHANGES TO THIS NOTICE: The Audiology Clinic will abide by the terms of the Notice currently in effect. We reserve the right to change the terms of this Notice at any time. Any new notice provisions will be effective for all protected health information that it maintains. NOTICE EFFECTIVE DATE: The effective date of the Notice is September 1, 2003. University of Cincinnati Speech and Hearing Clinic G65/344 French East Building Department of Communication Sciences & Disorders Cincinnati, Ohio 45267-0379 (513) 558-8502 33 ACKNOWLEDGEMENT OF NOTICE The University of Cincinnati Communication Sciences and Disorders Department Speech, Language, and Hearing Clinic I acknowledge that I have received the University of Cincinnati’s Speech, Language, and Hearing Clinic’s Notice Of Health Information Privacy Practices, effective as of April 14, 2003, which describes how my health information or my child’s will be used or disclosed. I understand that the Clinic reserves the right to change the Notice and its privacy practices at any time. _____________________________ Name – Please Print _____________________________ Signature _____________________________ Date 34 ADULT CASE HISTORY File No.___________Date:__________________ Last Name: __________________________First:__________________ Sex ( )M ( )F Date of Birth__________ How did you hear of us__________________________________________________________________________ GENERAL MEDICAL INFORMATION Who is your primary care physician?________________________________________________________________ Do you take any of the following types of medication (circle)? : blood pressure / heart disease / arthritis / daily aspirin / blood thinning / other ________________________________________________________- ___________________ Do you have any vision disorders? _________________________________________________________________ Do you have a chronic or serious illness?____________________________________________________________ Do you have any allergies?_______________________________________________________________________ Other relevant medical information: ________________________________________________________________ ____________________________________________________________________________________________ HEARING HISTORY Y N Do you have a known hearing loss? (Rt ear) (Lt ear) (Both) ________________________________________ Y N Is your hearing loss stable? _________________________________________________________________ Y N Is there a family history of hearing loss?________________________________________________________ Y N Have you had a previous hearing evaluation and where? __________________________________________ Y N Do you now, or have you ever, worn hearing aids? _______________________________________________ Y N Do you have noises in your ears (Rt ear) (Lt ear) (Both)?___________________________________________ Y N Do you have vertigo or dizziness?____________________________________________________________ Y N Have you ever had recreational, military, or employment noise exposure ?_____________________________ Y N Do you have pain, discomfort, or drainage in the ear ?____________________________________________ Y N Do you have a history of ear infection?________________________________________________________ Y N Have you had ear surgery ?_________________________________________________________________ Y N Have you had an injury to your ears?__________________________________________________________ Other________________________________________________________________________________________ ____________________________________________________________________________________________ LISTENING SITUATIONS Please rank the top 4 listening situations in which it is important for you to hear well: 35 ___ conversation with 1 person ___ telephone ___ television ___ in the car ___ in small groups ___ in large groups ___ restaurants ___ movie / theatre ___ at religious services ___ in meetings ___ work places ___ outdoors ___ listening to music RELEASE OF INFORMATION I give permission for release of reports, test results, and recommendations to or from my family physician, the referral source, or others as specified. ___________________________________________________ __________________________ Signature Date PEDIATRIC CASE HISTORY File # _________ Date:____________ Last Name____________________________ First Name___________________________ Date of Birth _________ Sex ( )M ( )F Parent / Guardian_____________________________________________________________ How did you hear of us? _________________________________________________________________________ GENERAL MEDICAL INFORMATION What is the name of your child’s pediatrician? ________________________________________________________ Were there any pregnancy complications (Illness, accident, medications)? __________________________________ ____________________________________________________________________________________________ Were there any birth complications (Low birth weight, jaundice, anoxia, other) ? ______________________________ ____________________________________________________________________________________________ Has your child had a vision evaluation? (and where)____________________________________________________ Has your child had any serious illness (Mumps, rubella, cytomegalovirus, other)?______________________________ Is there a history of ear infection? __________________________________________________________________ Has your child had ear surgery or injury to the ear ?____________________________________________________ Does your child have any allergies? ________________________________________________________________ Is your child currently taking any medications? - ________________________________________________________ Other relevant medical information: ________________________________________________________________ HEARING LOSS AND DEVELOPMENTAL INFORMATION Is there a previously documented hearing loss (where tested and what age)? ________________________________ ____________________________________________________________________________________________ Is there a family history of childhood hearing loss? _____________________________________________________ Is your child aware of environmental sounds and other’s speech? _________________________________________ 36 Is your child’s speech and language age appropriate? __________________________________________________ Is your child currently in speech therapy (and where) ? __________________________________________________ Is your child’s motor development age appropriate? ____________________________________________________ Does your child have any known behavioral disorders or coexisting handicaps ? ______________________________ ____________________________________________________________________________________________ OTHER INFORMATION What are the sex and ages of siblings? _____________________________________________________________ What is your child’s school, grade, and teacher’s name? ________________________________________________ How would you rate performance in school? _________________________________________________________ Does your child currently wear hearing aids? _________________________________________________________ How does your child generally communicate (sign language, speech, gestures)? _____________________________ ___________________________________________________________________________________________ RELEASE OF INFORMATION I give permission for release of reports, test results, and recommendations to or from the pediatrician, the referral source, or others as specified. ____________________________________________ ______________________ Signature (Relation to child) Date SAMPLE FORMAT FOR EVALUATION REPORT Name: ____________________________ Clinician:______________________ Parent/Guardian:____________________ Preceptor:____________________ Address: __________________________ Evaluation:____________________ Telephone: ________________________ Birth Date: ________________________ ________________________________________________________________________ was seen for _______________________________________________________ at the request of _________________________________. Background: ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Evaluation:____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 37 ______________________________________________________________________________ ______________________________________________________________________________ Summary:_____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Recommendations: ______________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ RELEASE/CLEARANCE FORM UNIVERSITY OF CINCINNATI COMMUNICATION SCIENCES AND DISORDERS Cincinnati, OH 45267-0379 POLICIES Each patient is assigned to a faculty member, who remains responsible for all services provided to that patient. Students training audiologists will observe diagnostic and therapy procedures and will work with patients under the supervision of the responsible staff member. Videotapes, audiotapes, films, or photographs may be utilized for educational or research purposes. In all such activities, maximum efforts are made to ensure the confidentiality of all information concerning individual patients; and no unauthorized persons are given access to clinical or personal information. Unless specified otherwise, reports will be sent upon request to medical, social service, and educational facilities. 38 _________________________________ I understand, consent to, and agree to abide by the policies set forth above. _____________________ _______________________________________________ (Date) (Signature) University of Cincinnati G65 French East Building 7001 Reading Road PO Box 670379 Cincinnati, OH 45237 Cincinnati, OH 45267-0379 (513) 558-8501 HEARING AID PURCHASE AGREEMENT Patient: __________________________________ Today’s Date: _______________ Fitting Date: _____________ Description Serial Number Qty Price Misc. Total Rt. Ear Lt Ear Total: Battery size: _________ Deposit: Balance: TERMS: Fifty percent of the purchase price is required at the time of order. Balance is payable upon delivery. We are happy to submit your insurance claims. If your insurance does not pay all that is expected, you are responsible for the unpaid balance. The amount not paid by your insurance carrier will be billed to you. 39 RIGHT TO RETURN HEARING AIDS AND RECEIVE A REFUND Under Ohio Law (O.R.C. 1345.30), a consumer has the right to return purchased hearing aids for any reason within 30 days after they are originally delivered to the consumer, or a person acting on the consumer’s behalf, and to receive a refund of the consideration paid for the hearing aids less an amount specified to cover expenses incurred in connection with the hearing aids. Such refund shall be received no later than 15 days after presenting proof of payment for the hearing aids and returning them in the condition in which they were received, except for normal wear and tear. In such an event, the amount deducted from the refund, not to exceed 10% of the purchase price, will be ________________. The cost of earmolds and professional service fees is not refundable. WARRANTY Unless otherwise indicated these devices are new and warranted by the manufacturer against defects in material and workmanship for a period of one year from the date the devices are received by the patient. This warranty shall not apply if the failure of the devices is due to abuse or mishandling. This warranty does not cover earmolds, tubing, batteries, or other related hearing services. The devices covered by this agreement, including supplies and accessories for these articles, constitute sale of tangible personal property used to supplement impaired function of the human body (i.e. hearing) and therefore are exempt from sales tax as per HB 703, effective 1/16/81. The purchaser is advised that any examination, fitting, recommendation, or representation made in connection with the sale of hearing aids is not an examination, diagnosis, or prescription made by a person licensed to practice medicine in this state and therefore must not be regarded as medical opinion or advice. The purchaser has further been advised that the FDA has determined that health interests are best served if a medical evaluation is obtained by a licensed physician (preferably an ear, nose & throat physician) before purchasing hearing aids. The undersigned does not desire a medical evaluation before purchase. ___________________________________________ ________________________________________ Patient Signature Audiologist Signature and License Number University of Cincinnati SPEECH, LANGUAGE, & HEARING CLINIC P.O. Box 670379 Cincinnati, OH 45267-0379 513-558-8502 Professional Services Documentation Name___________________________________ Services: ESL Evaluation___ Speech-Language Evaluation___ Birthdate________________________________ ESL Therapy___ Speech-Language Therapy___ Primary Diagnosis__________ Treatment Diagnosis___________ Language/Literacy Enrichment Group Services (LLEG)___ Student Clinician Name__________________________________ Audiological Evaluation___ Hearing Aid Services___ Student Clinician Signature_______________________________ Other__________________________________________ Preceptor/Provider Name/Title___________________________________________ Preceptor/Provider Signature_____________________________________________License #_________________________ Goals: _____________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 40 Date of CPT Intervention/Progress Time Prov. Service Code Spent Initials 41 Professional Services Documentation - p. 2 ICD-9 Diagnostic Codes SLP CPT Treatment Codes ICD-9 Diagnostic Codes Hearing 92609 Therapeutic services for the use of speech- Medical Diagnosis V71.8 Normal Hearing generating device, including programming and 335.20 Amyotrophic Lateral 380.10 Otitis externa modification Sclerosis 380.4 Impacted cerumen 92610 Evaluation of oral and pharyngeal swallowing 290 Alzheimer’s- dementia (senile) 381.4 Serous otitis media w/effusion function [For motion fluoroscopic evaluation of 299.80 Asperger’s current 381.81 Eustachian tube dysfunction swallowing function, use 92611] 299.00 Autism, infantile 384.20 Tymp. membrane perforation 92611 Motion fluoroscopic evaluation of swallowing 343.9 Cerebral Palsy 386.10 Vertigo, Peripheral function by cine or video recording 783.40 Developmental delay 386.5 Labyrinthine Dysf. Unspec. 92612 Flexible fiberoptic endoscopic evaluation of 758.0 Down’s Syndrome 388.01 Presbycusis swallowing by cine or video recording 332.0 Parkinson’s Disease 388.12 Noise Induced 92614 Flexible fiberoptic endoscopic evaluation, Language 388.2 Sudden laryngeal sensory testing by cine or video recording 438.0 Late effect of cerebrovascular 388.31 Tinnitus, subjective 92616 Flexible fiberoptic endoscopic evaluation of disease, cognitive deficits 388.32 Tinnitus, objective swallowing and larnygeal sensory testing by cine or 438.10 Late effect of cerebro- 388.60 Otorrhea video recording vascular disease, speech and 388.70 Otalgia 92597 Evaluation for use and/or fitting of voice language deficits, unspecified 389.03 Hearing loss, Conductive prosthetic device to supplement oral speech 438.11 Late effect of cerebro- 389.18 Sensorineural hearing loss, HCPCS (G0201) Modification or training in use of vascular disease, aphasia combined types voice prosthetic 438.12 Late effect of cerebro- 389.2 Mixed Time Based: vascular disease, dysphasia 389.7 Congenital/Acquired 96105 Assessment of aphasia (includes assessment of 781.3 Dysgraphia 780.4 Dizziness, Giddiness expressive and receptive speech and language function, 784.3 Aphasia 951.5 Traumatic/SN language comprehension, speech production ability, 784.5 Language disorder SLP CPT Treatment Codes reading, spelling, writing, eg. By Boston Diagnostic 784.61 Alexia and Dsylexia 92506 Evaluation of speech, Aphasia Examination) with interpretation and report, (organic) language, voice, communication, per hour Cognitive-Linguistic and/or auditory processing disorder Audiology CPT Treatment Codes Learning (includes aural rehab), individual 92551 Pure Tone Screening, Air 314.00 ADD 92507 Treatment of speech, 92552 Pure Tone Thresholds, Air 314.01 ADHD language, voice, communication, 92553 Pure Tone Thresholds, Air and Bone 315.0 Specific reading disorder and/or auditory processing disorder 92555 SRT 315.02 Developmental dyslexia (includes aural rehab), two or more 92556 SRT with Speech Discrimination reading individuals 92557 Comprehensive Audiogram 315.09 Other spelling difficulty 92526 Treatment of swallowing 92567 Tympanometry 315.2 Learning disorder, other dysfunction and/or oral function for 92568 Acoustic Reflex specific feeding 92569 Acoustic Reflex Decay 781.3 Dysgraphia 92597 Evaluation for use and/or 92582 Conditioned Play Audio Articulation/Phonology fitting of voice prosthetic or 92584 Electrocochleography 438.81 Other late effect of cerebro- augmentative/alternative 92585 ABR vascular disease, apraxia communication device to supplement 92589 Central Auditory Function 784.4 Dysarthria oral speech ENG 784.5 Articulation disorder 92598 Modification of voice 92541 Spontaneous and Horizontal Gaze 784.69 Apraxia prosthetic or augmentative/alternative 92542 Positional Tests (Standard and Dix-Hallpike) Fluency communication device to supplement 92543 Calorics 307.0 Stuttering, stammering oral speech 92544 Optokinetics Voice 92605 Evaluation for prescription of 92545 Oscillating Gracking 306.1 Pyschogenic dysphonia non-speech-generating augmentative 92547 Vertical Leads 749.00 Cleft palate unspecified and alternative communication device 92599 ENG Fistula Test 749.10 Cleft lip unspecified 92606 Therapeutic service(s) for the Hearing Aids 749.20 Cleft lip with cleft palate use of non-speech-generating device, 92590 Hearing Aid Evaluation, Monaural unspecified including programming and 92591 Hearing Aid Evaluation, Binaural 784.41 Aphonia modification 92592 Hearing Aid Fit/Check, Monaural 784.49 Voice disturbance: 92607 Evaluation for prescription for 92593 Hearing Aid Fit/Check, Binaural hoarseness, hyper/hyponasal speech-generating augmentative and 92594 Electroacoustic Check, Monaural Auditory Processing alternative communication device; 92595 Electroacoustic Check, Binaural 388.40 Auditory perception, face-to-face with the patient; V5241 Dispensing Fee, Monaural Hearing Aid, any abnormal evaluation, first hour type 388.42 Hyperacusis 92608 Each additional 30 minutes V5262 Hearing Aid, Disposable, any type, monaural 41 Dysphagia [Use 92608 in conjunction with V5263 Hearing Aid, Disposable, any type, binaural 438.82 Other late effect of cerebro- 92607] V5264 Ear mold/insert, not disposable, any type vascular disease, dysphagia 787.2 Dysphagia 41 APPENDIX C CODE OF ETHICS THE AMERICAN ACADEMY OF AUDIOLOGY - 1994 THE AMERICAN SPEECH-LANGUAGE- HEARING ASSOCIATION 42 AMERICAN ACADEMY OF AUDIOLOGY CODE OF ETHICS PREAMBLE The Code of Ethics of the American Academy of Audilogy specifies professional standards that allow for the proper discharge of audiologist’s responsibilities to those served, and that protect the integrity of the profession. The Code of Ethics consists of two parts. The first part, the Statement of Principles and Rules, presents precepts that members of the Academy agree to uphold. The second part, the Procedures, provides the process which enables enforcement of the Principles and Rules. PART 1. STATEMENT OF PRINCIPLES AND RULES Principle 1. Members shall provide professional services with honesty and compassion, and shall respect the dignity, worth, and rights of those served. Rule 1a: Individuals shall not limit the delivery of professional services on any basis that is unjustifiable or irrelevant to the need for the potential benefit from such services. Principle 2. Members shall maintain high standards of professional competence in rendering services, providing only those professional services for which they are qualified by education and experience. Rule 2a: Individuals shall use available resources, including referrals to other specialists, and shall not accept benefits or items of personal value for receiving or making referrals. Rule 2b: Individuals shall exercise all reasonable precautions to avoid injury to persons in the delivery of professional services. Rule 2c: Individuals shall not provide services except in a professional relationship, and shall not discriminate in the provision of services to individuals on the basis of sex, race, religion, natural origin, sexual orientation, or general health. Rule 2d: Individuals shall provide appropriate supervision and assume full responsibility for services delegated to supportive personnel. Individuals shall not delegate any service requiring professional competence to unqualified persons. Rule 2e: Individuals shall not permit personnel to engage in any practice that is a violation of the Code of Ethics. 43 Rule 2f: Individuals shall maintain professional competence, including participation in continuing education. Principle 3. Members shall provide only services and products that are in the best interest of professional services. Rule 3a: Individuals shall not reveal to unauthorized persons any professional or personal information obtained from the person served professionally, unless required by law. Principle 4. Members shall provide only services and products that are in the best interest of those served. Rule 4a: Individuals shall not exploit persons in the delivery of professional services. Rule 4b: Individuals shall not charge for services not rendered. Rule 4c: Individuals shall not participate in activities that constitute a conflict of professional interest. Rule 4d: Individuals shall not accept compensation for supervision or sponsorship beyond reimbursement of expenses. Principle 5. Members shall provide accurate information about the nature and management of communicative disorders and about the services and products offered. Rule 5a: Individuals shall provide persons served with the information a reasonable person would want to know about the nature and possible effects of services rendered, or products provided. Rule 5b: Individuals may make a statement of prognosis, but shall not guarantee results, mislead, or misinform persons served. Rule 5c: Individuals shall not carry out teaching or research activities in a manner that constitutes an invasion of privacy, or that fails to inform persons fully about the nature and possible effects of these activities, affording all persons informed free choice of participation. Rule 5d: Individuals shall maintain documentation of professional services rendered. 44 PRINCIPLE 6. Members shall comply with the ethical standards of the Academy with regard to public statements. Rule 6a: Individuals shall not misrepresent their educational degrees, training, credentials, or competence. Only degrees earned from regionally accredited institutions in which training was obtained in audiology, or a directly related discipline, may be used in public statements concerning professional services. Rule 6b: Individuals’ public statements about professional services and products shall not contain representations or claims that are false, misleading, or deceptive. PRINCIPLE 7. Members shall honor their responsibilities to the public and to professional colleagues. Rule 7a: Individuals shall not use professional or commercial affiliations in any way that would mislead or limit services to persons served professionally. Rule 7b: Individuals shall inform colleagues and the public in a manner consistent with the highest professional standards about products and services they have developed. PRINCIPLE 8. Members shall uphold the dignity of the profession and freely accept the Academy’s self-imposed standards. Rule 8a: Individuals shall not violate these Principles and Rules, nor attempt to circumvent them. Rule 8b: Individuals shall not engage in dishonesty or illegal conduct that adversely reflects on the profession. Rule 8c: Individuals shall inform the Ethical Practice Board when there are reasons to believe that a member of the Academy may have violated the Code of Ethics. Rule 8d: Individuals shall cooperate with the Ethical Practice Board with any matter related to the Code of Ethics. 45 PART II. PROCEDURES FOR THE MANAGEMENT OF ALLEDGED VIOLATIONS INTRODUCTION Members of the American Academy of Audiology are obligated to uphold the Code of Ethics of the Academy in their personal conduct and in the performance of their professional duties. To this end it is the responsibility of each Academy member to inform the Ethical Practice Board of possible Ethics Code violations. The processing of alleged violations of the Code of Ethics will follow the procedures specified below in an expeditious manner to ensure that violations of ethical conduct by members of the Academy are halted in the shortest time possible. PROCEDURES 1. Suspected violations of the Code of Ethics should be reported in letter format giving documentation sufficient to support the alleged violation. Letters must be signed and addressed to: Chair, Ethical Practice Board American Academy of Audiology 8201 Greensboro Drive Suite 300 McLean, VA 2210 2. Following receipt of the alleged violation the Board will request from the complainant a signed Waiver of Confidentiality indicating that the complainant will allow the Ethical Practice Board to disclose is/her name should this become necessary during investigation of the allegation. The Board may, under special circumstances, act in the absence of a signed Waiver of Confidentiality. 3. On receipt of the Waiver of Confidentiality signed by the complainant, or on the decision of the Board to assume the role of active complainant, the member(s) implicated will be notified by the Chair that an alleged violation of the Code of Ethics has been reported. Circumstances of the alleged violation will be described and the member(s) will be asked to respond fully to the allegation. 4. The Chair may communicate with other individuals, agencies, and/or programs, for additional information as may be required for Board review. The accumulation of information will be accomplished as expeditiously as possible to minimize the time between initial notification of possible Code violation and final determination by the Ethical Practice Board. 5. All information pertaining to the allegation will be reviewed by members of the Ethical Practice Board and a finding reached regarding infractions of the Code. In cases of Code violation, the section(s) of the Code violated will be cited, and a sanction specified when the Ethical Practice Board decision is disseminated. 46 6. Members found to be in violation of the Code may appeal the decision of the Ethical Practice Board. The route of Appeal is by letter format through the Ethical Practice Board to the Executive Committee of the Academy. Requests for Appeal must: a. be received by the Chair, Ethical Practice Board, within 30 days of the Ethical Practice Board notification of violation. b. state the basis for the appeal, and the reason(s) that the Ethical Practice Board decision should be c. not offer new documentation. The decision of the Executive Committee regarding Appeals will be considered final. SANCTIONS 1. Reprimand. The minimum level of punishment for a violation consists of a reprimand. Notification of the violation and the sanction is restricted to the member and the complainant. 2. Cease and Desist Order. Violator(s) may be required to sign a Cease and Desist Order which specifies the non-compliant behavior and the terms of the Order. Notification of the violation and the sanction is made to the member and the complainant, and may on two-thirds vote of the Ethical Practice Board be reported in an official publication. 3. Suspension of Membership. Suspension of membership may range from a minimum of six (6) months to a maximum of twelve (12) months. During the period of suspension the violator may not participate in official Academy functions. Notification of the violation and the sanction is made to the member and the complainant and is reported in official publications of the Academy. Notification of the violation and the sanction may be extended to others and determined by the Ethical Practice Board. No refund of dues or assessments shall accrue to the member. 4. Revocation of Membership. Revocation of membership will be considered as the maximum punishment for a violation of the Code. Individuals whose membership is revoked are not entitled to a refund of dues or fees. One year following the date of membership revocation the individual may reapply for, but is not guaranteed, membership through normal channels and must meet the membership qualifications in effect at the time of application. Notification of the violation and the sanction is made to the member and the complainant and is reported in official publications of the Academy for at least three (3) separate issues during the period of revocation. Special notification, as determined by the Ethical Practice Board, may be required in certain situations. RECORDS 47 1. A Central Record Depository shall be maintained by the Ethical Practice board which will be kept confidential and maintained with restricted access. 2. Complete records shall be maintained for a period of five (5) years and then destroyed. 3. Confidentiality shall be maintained in all Ethical Practice Board discussion, correspondence, communication, deliberation, and records pertaining to members reviewed by the Ethical Practice Board. 4. No Ethical Practice Board member shall give access to records, act or speak independently, or on behalf of the Board, without the expressed permission of the Board members then active, to impose the sanction of the Board, or to interpret the findings of the Board in any manner which may place members of the Board, collectively or singly, at financial, professional, or personal risk. 5. A Book of Precedents shall be maintained by the Ethical Practice Board which shall form the basis for future findings of the Board. 48 AMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION Code of Ethics Last Revised January 1, 2003 Preamble The preservation of the highest standards of integrity and ethical principles is vital to the responsible discharge of obligations by speech-language pathologists, audiologists, and speech, language, and hearing scientists. This Code of Ethics sets forth the fundamental principles and rules considered essential to this purpose. Every individual who is (a) a member of the American Speech-Language- Hearing Association, whether certified or not, (b) a nonmember holding the Certificate of Clinical Competence from the Association, (c) an applicant for membership or certification, or (d) a Clinical Fellow seeking to fulfill standards for certification shall abide by this Code of Ethics. Any violation of the spirit and purpose of this Code shall be considered unethical. Failure to specify any particular responsibility or practice in this Code of Ethics shall not be construed as denial of the existence of such responsibilities or practices. The fundamentals of ethical conduct are de-scribed by Principles of Ethics and by Rules of Ethics as they relate to the conduct of research and scholarly activities and responsibility to persons served, the public, and speech-language pathologists, audiologists, and speech, language, and hearing scientists. Principles of Ethics, aspirational and inspirational in nature, form the underlying moral basis for the Code of Ethics. Individuals shall observe these principles as affirmative obligations under all conditions of professional activity. Rules of Ethics are specific statements of minimally acceptable professional conduct or of prohibitions and are applicable to all individuals. 49 Principle of Ethics I Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or participants in research and scholarly activities and shall treat animals involved in re-search in a humane manner. Rules of Ethics A. Individuals shall provide all services competently. B. Individuals shall use every resource, including referral when appropriate, to ensure that high-quality service is provided. C. Individuals shall not discriminate in the delivery of professional services or the conduct of research and scholarly activities on the basis of race or ethnicity, gender, age, religion, national origin, sexual orientation, or disability. D. Individuals shall not misrepresent the credentials of assistants, technicians, or support personnel and shall inform those they serve professionally of the name and professional credentials of persons providing services. E. Individuals who hold the Certificates of Clinical Competence shall not delegate tasks that require the unique skills, knowledge, and judgment that are within the scope of their profession to assistants, technicians, support personnel, students, or any nonprofessionals over whom they have supervisory responsibility. An individual may delegate support services to assistants, technicians, support personnel, students, or any other persons only if those services are adequately supervised by an individual who holds the appropriate Certificate of Clinical Competence. Ethics I -186 / 2001 ASHA Desk Reference 2002 Volume 1 • Cardinal Documents of the Association F. Individuals shall fully inform the persons they serve of the nature and possible effects of services rendered and products dispensed, and they shall inform participants in research about the possible effects of their participation in re- search conducted. G. Individuals shall evaluate the effectiveness of services rendered and of products dispensed and shall provide services or dispense products only when benefit can reasonably be expected. H. Individuals shall not guarantee the results of any treatment or procedure, directly or by implication; however, they may make a reason-able statement of prognosis. I. Individuals shall not provide clinical services solely by correspondence. 50 J. Individuals may practice by telecommunication(for example, telehealth/e-health), where not prohibited by law. K. Individuals shall adequately maintain and appropriately secure records of professional services rendered, research and scholarly activities conducted, and products dispensed and shall allow access to these records only when authorized or when required by law. L. Individuals shall not reveal, without authorization, any professional or personal information about identified persons served professionally or identified participants involved in research and scholarly activities unless required by law to do so, or unless doing so is necessary to protect the welfare of the person or of the community or otherwise required by law. M. Individuals shall not charge for services not rendered, nor shall they misrepresent services rendered, products dispensed, or research and scholarly activities conducted. N. Individuals shall use persons in research or as subjects of teaching demonstrations only with their informed consent. O. Individuals whose professional services are adversely affected by substance abuse or other health-related conditions shall seek professional assistance and, where appropriate, withdraw from the affected areas of practice. Principle of Ethics II Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence. Rules of Ethics A. Individuals shall engage in the provision of clinical services only when they hold the appropriate Certificate of Clinical Competence or when they are in the certification process and are supervised by an individual who holds the appropriate Certificate of Clinical Competence. B. Individuals shall engage in only those aspects of the professions that are within the scope oft heir competence, considering their level of education, training, and experience. C. Individuals shall continue their professional development throughout their careers. D. Individuals shall delegate the provision of clinical services only to: (1) persons who hold the appropriate Certificate of Clinical Competence;(2) persons in the education or certification process who are appropriately supervised by an individual who holds the appropriate Certificate of Clinical Competence; or (3) assistants, technicians, or support personnel who are adequately supervised by an individual who holds the appropriate Certificate of Clinical Competence. 51 E. Individuals shall not require or permit their professional staff to provide services or conduct research activities that exceed the staff member’s competence, level of education, training, and experience. F. Individuals shall ensure that all equipment used in the provision of services or to conduct research and scholarly activities is in proper working order and is properly calibrated. Principle of Ethics III Individuals shall honor their responsibility to the public by promoting public understanding of the professions, by supporting the development of services designed to fulfill the unmet needs of the public, and by providing accurate information in all communications involving any aspect of the professions, including dissemination of research findings and scholarly activities. Rules of Ethics A. Individuals shall not misrepresent their credentials, competence, education, training, experience, or scholarly or research contributions. B. Individuals shall not participate in professional activities that constitute a conflict of interest. C. Individuals shall refer those served profession-ally solely on the basis of the interest of those being referred and not on any personal financial interest. D. Individuals shall not misrepresent diagnostic information, research, services rendered, or products dispensed; neither shall they engage in any scheme to defraud in connection with obtaining payment or reimbursement for such services or products. E. Individuals’ statements to the public shall pro-vide accurate information about the nature and management of communication disorders, about the professions, about professional services, and about research and scholarly activities. F. Individuals’ statements to the public—advertising, announcing, and marketing their professional services, reporting research results, and promoting products— shall adhere to prevailing professional standards and shall not contain misrepresentations. Principle of Ethics IV Individuals shall honor their responsibilities to the professions and their relationships with colleagues, students, and members of allied professions. Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious inter-professional and intraprofessional relationships, and accept the professions’ self-imposed standards. Rules of Ethics A. Individuals shall prohibit anyone under their supervision from engaging in any practice that violates the Code of Ethics. 52 B. Individuals shall not engage in dishonesty, fraud, deceit, misrepresentation, sexual harassment, or any other form of conduct that adversely reflects on the professions or on the individual’s fitness to serve persons professionally. C. Individuals shall not engage in sexual activities with clients or students over whom they exercise professional authority. D. Individuals shall assign credit only to those who have contributed to a publication, presentation, or product. Credit shall be assigned in proportion to the contribution and only with the contributor’s consent. E. Individuals shall reference the source when using other persons’ ideas, research, presentations, or products in written, oral, or any other media presentation or summary. F. Individuals’ statements to colleagues about professional services, research results, and products shall adhere to prevailing professional standards and shall contain no misrepresentations. G. Individuals shall not provide professional services without exercising independent professional judgment, regardless of referral source or prescription. H. Individuals shall not discriminate in their relationships with colleagues, students, and members of allied professions on the basis of race or ethnicity, gender, age, religion, national origin, sexual orientation, or disability. I. Individuals who have reason to believe that the Code of Ethics has been violated shall inform the Board of Ethics. J. Individuals shall comply fully with the policies of the Board of Ethics in its consideration and adjudication of complaints of violations of the Code of Ethics. Reference this material as: American Speech-Language-Hearing Association. Code of ethics (revised).ASHA Supplement, 23, pp. 13–15. 53
"DOCTOR OF AUDIOLOGY"