DOCTOR OF AUDIOLOGY by yaofenji

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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.




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