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, and auscultation. 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 areas 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
