Evaluation of Clinical Data Documentation Quality in Speech Therapy Clinics at Hamadan University of Medical Sciences: A Ten-Year Retrospective Study

Abstract

Background and Aim: Speech-language pathology and swallowing is a field of rehabilitation sciences focused on the evaluation, diagnosis, and treatment of speech and language disorders. Because university clinics play key roles in clinical care, education, and data production, high-quality documentation is essential. Incomplete or inconsistent records can undermine clinical decisions, continuity of care, and research. This study evaluated the completeness, accuracy, and coherence of clinical data documentation in speech therapy records of clinics affiliated with the Faculty of Rehabilitation Sciences of Hamadan over a ten-year period.

Materials and Methods: This study was a descriptive cross-sectional study with a retrospective design. The study population included all speech therapy records registered in four clinics affiliated with Hamadan University of Medical Sciences between 2013 and 2023. Using a census sampling method, a total of 1,468 records were included in the analysis. Data were extracted using a researcher-made checklist based on the core components of speech therapy clinical records and analyzed using descriptive statistics (frequency and percentage) in SPSS.

Results: A review of 1,468 speech-language therapy records revealed substantial deficiencies in the documentation of key clinical information. The highest rates of missing documentation were observed for referral source (91.1%), place of residence (73.5%), bilingualism status (70.1%), and medical diagnosis (69.3%). In 37% of the records, documentation was limited to the initial assessment, with no information regarding continuity of treatment. Age and speech diagnosis were not documented in 3.5% and 3.2% of the records, respectively. In addition, the number of treatment sessions was incompletely or inconsistently documented in 97 records (6.6% of all records). The highest proportion of clients was in the 3–6-year age group (51.3%). Among the documented speech diagnoses, speech sound disorders (18.9%), speech and language delay (18.1%), and fluency disorders (18.0%) were the most frequently reported. Among the documented medical diagnoses, laryngeal injury, cleft lip and palate, and cerebral palsy were the most frequent. Across centers, the proportion of regularly documented data ranged from approximately 35% to 52% at the descriptive level.

Conclusion: The findings indicate structural weaknesses in clinical data documentation in the studied speech therapy clinics. Implementing standardized documentation forms, providing targeted training for students and clinicians, and establishing an electronic health record system may improve documentation quality, enhance continuity of care, and increase the research utility of clinical data. These results can inform strategic planning for the development of rehabilitation services in medical universities across the country.