Medical Documentation Essential Best Practices – Distance Learning/Self-Study Course

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

Professional medical charting and reports are vital for:

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

Class Topics:

  • Making it safe, effective, and practical
    • Ways to learn and hone charting skills
    • Paper vs. electronic health records systems: comparisons
    • Pros and cons of templates, checklists, and narratives
    • Custodianship and transfer of patient records
  • Essential contents of a SOAP notes and HPIs: essential and appropriate contents and terminology
    • Subjective
    • Objective
    • Assessment
    • Plan

Medical Documentation Essential Best Practices – Distance Learning/Self-Study Course

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

Professional medical charting and reports are vital for:

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

Class Topics:

  • Making it safe, effective, and practical
    • Ways to learn and hone charting skills
    • Paper vs. electronic health records systems: comparisons
    • Pros and cons of templates, checklists, and narratives
    • Custodianship and transfer of patient records
  • Essential contents of a SOAP notes and HPIs: essential and appropriate contents and terminology
    • Subjective
    • Objective
    • Assessment
    • Plan