OnlineCE - Course

State Approvals Webinars Blog Login

Documentation 161 : Keys to Clinical Documentation

Credit Hours(s)2.0

InstructorsPaul Sherman, DC

Price$40.00 USD

Format(s)AudioVisual Course

Educational Objectives

Recognize the key components regarding good documentation and record keeping
Identify the legal requirements of informed consent and the key elements of the informed consent process
Discuss why doctors are held to higher standards
Describe the 21 NCQA guidelines for record keeping
Document progress notes (SOAP) to meet insurance guidelines and medical necessity
Apply the PARTS system and its transformation utilizing a new method AIR S & M
Utilize CMT coding appropriately
Utilize E/M (Evaluation/Management) coding appropriately to meet insurance guidelines and medical necessity
Identify the 3 categories and 2 subcategories of E/M codes
Identify the 5 levels of E/M services for new and established patients
Identify the 7 components (descriptors) used to determine the level of E/M service
Select the appropriate level of E/M services utilizing 7 simple steps

Approved States/Territories