What Should an SLP Do If You Document on the Wrong Patient?

What to do if you document on the wrong patient as an SLP, why it happens, and how to prevent it. Plus a CE resource on medical error prevention

What should an SLP do if I documented in the wrong patient's chart?

Has this ever happened to you?

You're following up on a patient you evaluated yesterday. Reading through the SLP report, the H&P, the medical progress notes, and... something isn't matching up.

With sweaty palms and a pit in your stomach, you bounce back and forth between the SLP note and the recent MD progress note, and then it hits you: did I document on the wrong patient?

If this has happened to you, you're not alone, and it's more common than most SLPs are willing to admit out loud.

Here's what to actually do about it, and how to prevent it from happening again.

Why Documentation Errors Happen in Medical SLP Settings

There are many, many reasons that documentation errors can occur.

I suspect a big one is that, more and more each year, we SLPs are tasked with seeing more patients with fewer resources and less time.

There are also a lot of distractions-- Voceras, pages, phone calls, sidebar conversations, ventilators...

Despite our best efforts, our brains can only manage so many high-load tasks at once. Errors are bound to happen.

We're human. We're overworked and tired. We're doing our best with the time we're given. That doesn't make an error desirable, but it does make it understandable. And understanding why medical errors happen to SLPs is the first step to actually preventing it.

What do I do as an SLP if I documented on the wrong patient or in the wrong chart?

Much of this will depend on policies at your workplace, and if any negative events occurred as a result of the error, so always check your policies and with management before taking action.

Generally, you'll probably want to:

Notify your supervisor/manager. They will help determine next steps which may include incident reporting through your compliance system.
Determine if any negative consequences resulted (for example, incorrect diet was provided). Discuss with your supervisor.
Ensure the correct patient's record receives the proper documentation. Make sure you include the correct date and time of service.
When cleared by management, strike the incorrect note from the incorrect chart. Write the correct note for that patient, making sure you include the correct date and time of service.

I'm an SLP and made a medical error. Is my license going to get taken away?

This is probably the part that keeps us up at night.

And there's no black-and-white, cut-and-dry answer. The reality is, medical errors have differing degrees of severity depending on what happened.

Any disciplinary action, internally or against a license, may depend on factors like:

Was patient harm caused and, if so, how grave was it?
When was this caught?
How quickly was it corrected?
Were internal processes and procedures followed?

A basic typo (like "swallowling" instead of "swallowing") is going to have a very different response than an error that resulted in actual patient harm.

Always be honest and self-report to your supervisor so they can guide you through next steps.

How do I prevent medical documentation errors as an SLP?

Nothing wakes us up more than our own medical errors. It's common to be on higher alert immediately following an error, and crucial to not let that attention slip again.

If the error resulted from a process issue-- seeing too many patients back to back, being able to open too many charts at one time, having to document in a high-distraction environment-- discuss remedies with your supervisor.

Easily distracted? Bring headphones or ear plugs, or something like Loops, to help you focus. Turn off notifications temporarily.

And it's not just external distractions. Our own systems can sometimes present challenges. Similar last names, sexes, and ages. Rooms next door to each other. Two charts that look nearly identical until you're three lines into the note and realize you're describing the wrong swallow study.

Too many charts open? Only open one or two charts at a time, ideally on two very distinct patients (eg, different sexes, ages, diagnoses, etc).

Always read your report before tapping "sign". Look at your report. Look at the patient's name and date of birth. Compare to the H&P and a recent progress note. If it doesn't add up, don't sign that report-- consider the possibility that you may be at risk of a documentation-related medical error.

Learn about Medical Errors & the SLP in a Live ASHA CEU

Join Brooke Richardson and Will Farnham on Nov 11, 2026 for a live webinar on medical error prevention for SLPs. This course is designed to meet Florida requirements for SLPs, and is approved for ASHA CEUs.

Read details and register for the webinar.

Categories: : Acute care, Documentation, Medical errors, Swallowing