Documentation and Report-Writing

for Better Care, Reimbursement, Referral-building, and Malpractice Defense

With Instructor Anthony Von der Muhll, L.Ac., DAOM, DNBAO, FAIPM


Medical Documentation: Essential Best Practices

Live Webinar Workshop & Distance-Learning Course

Professional medical documentation skills are vital for:

  • Improving outcomes and learning directly from your patient cases
  • Building referral relationships and improving coordination of care with other medical professionals
  • Supporting insurance reimbursement
  • Complying with records requests and surviving insurance audits
  • Defense in case of malpractice suits and complaints to regulatory agencies

Class Topics:

  • Bring your charting up to the highest standards of professionalism by reviewing and applying best practices in:
    • Organization and completeness
    • Appropriate use of medical terminology
    • Documenting case management and safety procedures
  • Techniques to save time and effort while improving quality
    • Pros and cons of templates, checklists, and narratives: avoiding the appearance of "rote" treatment
    • Custodianship and transfer of patient records: keeping it safe and legal
    • Further learning: developing charting skills for your areas of specialization

Class notes feature sample initial (History of Present Illness) and progress (SOAP) notes.

Billing managed care insurance? Our Report-Writing Workshop for Managed Care class can help with treatment authorization and reimbursement. Register for both classes for -10% off each.

Report-Writing for Managed Care: HMO, Personal Injury & Work Comp

Live Webinar Workshop & Distance-Learning Course

-- "Thanks a lot for providing the class to us; very professional and useful, helpful!" -- Shaoying Bai, LAc., Sacramento CA

Report-writing skills are vital for treatment authorization and reimbursement for HMO, Personal Injury and Work Comp cases.

Class Topics:

  • Documentation and reporting of subjective and objective measurements of functional capacities and other key baselines, including:
    • Standard, research-validated questionnaires to measure patient self-assessments of functional capacity
    • Pain scales: how to use them accurately and reliably
    • Findings from observation and inspection
    • Joint range-of-motion
    • Strength, sensory function, and tenderness scales
    • Measuring limb girth and skin lesions
    • Special tests and physical examinations
    • Non-quantifiable assessments of functional capacity
  • Setting appropriate treatment goals
  • Presenting outcomes and making recommendations for future care to support reimbursement and treatment authorization/re-authorization requests

Class notes include sample initial functional capacity evaluations and re-evaluation reports for managed care insurance.

Live webinar workshops feature instructor-lead peer review/feedback regarding student chart notes and reports.

Student Ratings and Comments

from evaluation from prior live class offering in 2016, as required by California Acupuncture Board

Respondents: 13 of 17 enrolled

Average rating: 99/100

  • “Anthony as always is superbly professional, knowledgeable, and encouraging improvements in clinical practice. Thank you!”  --Anonymous
  • “All of your classes have been instrumental in my ability to improve patient care–but it could be a 2-day course to cover more. Thank you!”  –Jennifer Root, L.Ac.
  • “I always enjoy Anthony’s classes, very helpful info.”  --Anonymous

For Certification in Acupuncture Orthopedics, either the live webinar (8 hours), or the distance-learning class (5 hours) + one live 3-hour Case Consultation meeting focused on medical documentation is required.

Treating the Low Back, Neck and Shoulder with Classical and Modern Acupuncture

Hands-on training and practice with Anthony Von der Muhll, LAc, DAOM

September 21, 2024, York, United Kingdom

September 28-29, 2024, Basel, Switzerland

Advanced Clinical Approaches: Low Back, Core & Pelvic Girdle

Saturday, September 21, 2024, 10:00-17:00

In-person only at the Northern College of Acupuncture, York, UK

Register through the Northern College of Acupuncture

NCCAOM PDAs approved

 

Comments from class evaluations:

"Great class and great series! So much information that’s immediately useful." -- Eunhye Kim

 

Treating the Low Back with Classical and Modern Acupuncture

Saturday, September 28, 2024, 9:00-17:00

In-person only at aava Zentrum für EEH und Eltern-Kind-Begleitung, Leonhardsberg 14, Basel, Switzerland

 

Treating the Neck and Shoulder with Classical and Modern Acupuncture

Sunday, September 29, 2024, 9:00-17:00

In-person only at aava Zentrum für EEH und Eltern-Kind-Begleitung, Leonhardsberg 14, Basel, Switzerland

 

TCM Fachverband members: contact TCM Fachverband for discount code for 10% off.

Clinical anatomy, kinesiology, and the jing-jin ("sinew meridians" or myofascial tracts)

  • Bones, muscles, discs and facet joints, and neurology
  • Posture and motion dysfunctions
  • The arthritic progression: strain/sprain, derangement, degeneration

History-taking: key diagnostic questions

  • "Red flag" symptoms of urgent/serious medical conditions potentially warranting referral to physician care: stenosis, tumors, infection, fractures, and neuropathies
  • Identifying the affected jing-jin ("sinew meridians" or myofascial tracts).
  • Differentiating symptoms of muscles, joint, disc, spinal cord, and nerve root injuries
  • Neural hypersensitization and psycho-social factors

Physical exam of the low back, neck and shoulder: how findings can guide acupuncture treatment

  • Classical jing-jin and modern orthopedic observation, inspection and palpation
  • Joint exam: active range-of-motion and passive stress testing of the spinal and shoulder joints
  • Examination for upper and lower motor neuron lesions: deep tendon, and pathologic reflexes and sensory, and motor function
  • Manual strength testing and referred pain pattern charts for 35 key muscles of the low back, core and pelvic girdle, neck and shoulder
  • Special orthopedic tests for the back, neck and shoulder
  • Clinical flow charts to facilitate efficiency and accuracy in examination

Diagnosis and pattern identification

  • Jing-jin syndromes
  • Postural and motion dysfunctions
  • Muscle strains and myofascial pain
  • Radiculopathies and stenosis
  • Chronic back, neck and shoulder pain, spondylosis, arthritis, degenerative disc disease, scoliosis
  • Spinal spondylolistheses
  • Failed spinal surgery syndromes
  • For the low back: post-partum pain, insufficiency of the iliolumbar and sacrotuberous ligaments, and dysfunctions of the sacroiliac joint
  • For the neck and shoulder: cervical facet, glenohumeral and acromioclavicular joint pain

Treatment of the jing-jin and orthopedic conditions

 

For facility information only, contact:
078 926 00 94*
info@aavabasel.ch