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On Demand

Appropriate Documentation


Total CME Credit Hours: 1 Category I (Formal)

Education Types:
Category I (Formal) |  Risk Management
Topics:
Documentation |  Diagnosis
Faculty:
Becky Walters
Duration:
1 Hour



Description

In this timely, fast-paced session, we'll cover all the important aspects of Initial Assessment, the most important and often missing component of documentation. Documentation of the initial assessment is often confused with the diagnosis of the patient's condition. We'll cover why this mistake leaves medical record documentation lacking in the most important aspects of "doctor thinking". When these essential initial assessment components are missing, it's difficult to clarify the doctor's case management goals for the episode of active treatment. This "doctor thinking" is often conducted between the doctor's ears and not in the record, and so the lack of the initial assessment in your record can derail your best efforts at good documentation.

 

This course was presented in May 2016  Becky Walters, MCS-P  and sponsored by KMC University.

 

 

Handouts

Reviews

5
4
3
2
1

Overall:      4.2

Total Reviews: 47

Comments

Christine W - Naperville, Illinois

"The handout was helpful."

Sean V - Springfield, Illinois

"none at this time"

Rob G

"The program is good, the content is frustrating but that has more to do with the overall nature of reviewer and insurance compliance than the program. Becky did a good job in helping understand how to attempt to make a better note but but those style of notes only apply to an acute injury or acute exacerbation that may resolve. My irritation is more that I have to cater to the haste of the insurers that only want to look at one part of a note and use uneducated staff to review me and my care."

Kelly Astrid M - Chicago, Illinois

"Thank you! Very good information to know about what a reviewer is looking for and not looking for."

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