May 2025
Accountability When Signing Documentation
Part 1 of a 3-Part Series
Question:
I supervise a few speech-language pathologists (SLPs) at a not-for-profit agency. One of the SLPs unexpectedly left on medical leave. She left behind a couple of partially completed assessment reports and I’m not sure how to appropriately finish these off, including sign-off.
Answer:
Supervisory responsibilities in relation to documentation can be found on page 14 of ACSLPA’s Clinical Documentation and Record Keeping Guideline (2021). As stated in the guideline, “if a staff SLP or audiologist is unable to sign completed documentation, for example, due to events such as a sudden medical leave, the disclaimer “dictated/composed but not read by” should be included in the signature block of the report. This would include situations where the departing SLP or audiologist might have left a draft report that was not completely finalized, but contained the bulk of the content, and requires only minor modifications by the professional taking over for them, or by the supervisor. If the original SLP or audiologist is unable to sign off on the report, then the replacing professional or supervisor would sign off on the report, ensuring that the intent of their signature is clear (e.g., “this report was written by Anita Paul, R.SLP/R.Aud and has been reviewed by Jordan Jones, R.SLP/R.Aud”).
If a departing SLP or audiologist left behind a partially completed assessment, then the individual finalizing the assessment needs to document both their own name and the name of the original professional in the report. A short description of the change of professional in the background section of the report would typically suffice. The new SLP or audiologist taking over would need to review the previously completed assessment results, and complete or finalize the assessment as needed. The replacing SLP or audiologist would then become the author and sign the report as such.
It’s also important to remember that, as per Standard of Practice 4.4 Clinical Supervision, support personnel are not permitted to complete and sign-off on formal clinical reports as this is an activity that involves clinical interpretation.
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