Appropriate Documentation

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.