Medical Documentation: Essential Best Practices

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

Course Content

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

On-line, E-book and class notes feature a sample initial visit report (History of Present Illness)

Live class features instructor-lead peer review/feedback regarding student chart notes

The topics in this class are continued on Sunday, January 13, 9:00 a.m.-6:00 p.m., with Report-Writing for Managed Care: HMO, Personal Injury, and Workers Compensation

Take both classes for -10% off each.

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