Part 1: An Introduction to documentation. This section discusses why note taking is critical to
tell the story of your patient’s condition at the time of your evaluation, inclusive of co-
morbidities, pre-existing conditions, family and social considerations and medical-legal
implications. It also covers hand written notes vs. electronic medical records and the importance
of documenting at the academic standard.
Part 2: Reviews on how to conclude a chief complaint, history and what needs to be considered
in a physical examination. This covers in dept the required elements for chief complain, history
of present illness, review of systems, and past, family, and/or social history. This module also
covers the following components of a physical examination: observation, palpation, percussion,
Part 3: Coding and Spinal Examination: This module covers 99202-99205 and 99212-99215
inclusive of required elements for compliant billing. It reviews the elements for an extensive
review of systems, cervical and lumbar anatomy and basic testing. The course also covers the
basics of vertebra-basilar circulation orthopedic assessment.
Part 4: Neurological Evaluation: This module covers a complete motor and sensory evaluation
inclusive of reflex arcs with an explanation of Wexler Scales in both the upper and lower
extremities. The course breaks down testing for upper and lower motor neuron lesions along with
upper and lower extremity motor and sensory testing examinations.
Part 5: Documenting Visit Encounters: This module covers the S.O.A.P. note process for visit
encounters. It discusses the necessity for clinically correlating symptoms, clinical findings and
diagnosis with the area(s) treated. It also discusses how to modify treatment plans, diagnosis,
document collaborative care and introduce test findings between evaluations.
Part 6: Case Management and Treatment Orders: This module discusses how to document a
clinically determined treatment plan inclusive of both manual and adjunctive therapies. It
discusses how to document both short-term and long-term goals as well as referring out for
collaborative care and/or diagnostic testing. It also includes how to prognose your patient and
determine when MMI (Maximum Medical Improvement) has been attained.
Objective: To get the doctor to understand how to create a clinically accurate evaluation and
management document that accurately reflects the coding level billed.
How hours will be monitored: by Dr. Mark Studin and Christina Brillante.
Each video cannot be fast-forwarded and a post-test must be completed for each 1-2-hour section
|Instructor||Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, Chiropractor; Michael Barone DC, DISCN, DIBE; Bryan Weissman, DC|
|Subject Breakdown||12 credits Case Management and evaluation|
|Format||Distance - On-demand|