Educational Objectives: for Documentation

Hour 1 and 2

• Define the Problem Oriented Medical Record (POMR).
• Demonstrate taking a complete patient history.
• Define the Evaluation and Management examination for the musculoskeletal system.
• Define Outcome Assessment.
• Illustrate the P.A.R.T. format of documentation.
• Define proper Assessment for SOAP notes.
• Discuss proper documentation of treatment performed on each visit.
• Discuss proper documentation of treatment plans.
• Properly process requests for information and records

Hour 3

• Perform communication with patients and the public at large such that it informs, instructs and doesn't mislead.
• Discuss the parallels between accurate communication and ethical conduct.
• Administer healthcare practice compliant with HIPAA, state confidentiality statutes, and relevant rules, regulations and state court cases applicable to patient confidentiality.
• Comprehend the commercial, regulatory, social and familial interests seeking to obtain and/or are served by the release of patient information.
• Develop effective office systems and policies for securing and documenting patients’ informed consent
• Appropriately disclose charges

Hour 4

• Assess court and Office of Inspector General rulings relating to anti-kickback restrictions.
• Demonstrate how anti-kickback and Stark legislation is both viewed and enforced by relevant professional boards and state and federal enforcement agencies to avoid fraud
• Explain how to avoid misleading claims
• Identify specific conduct and activities within the practice of healthcare that violate a host of regulatory and statutory proscriptions relating to patient referral arrangements.
• Properly Delegate authority in your office
• Identify parallels between Stark self-referral laws and anti-kickback restrictions.