Impeccable Documentation of the Foundational Visit of an Episode – Part 2

With Kathy Mills Chang, MCS-P, KMC University
Recorded August, 7th 2014 View Recording

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Join our special guest Kathy Mills Chang, MCS-P—documentation expert and founder of KMC University in this second of a three-part series on documentation.

When proper time is devoted to flawless documentation at the beginning of an episode of care, the foundation has been set for more simple and speedy documentation day to day. But what constitutes this flawless documentation? This overview session will outline the most significant components of initial visit documentation to lay the foundation for proper case management for your patient’s entire episode of care. Whether a new patient or returning patient with a new or similar condition, the documentation must contain essential elements to be considered complete, and to properly establish medical necessity for the ongoing care of that episode. Learn to apply these elements impeccably, every time.

Learning Objectives/Program Goals

  • Understand the appropriate documentation for initial visits including E/M guidelines and key components of care
  • Report the necessary components of documentation for the beginning of an episode of care, from initial history, through exam, diagnosis and treatment planning.
  • Interpret the patient’s history to drive the exam, yielding the proper diagnosis and recommended treatment.
  • Produce appropriate initial visit documentation, even when faced with an exacerbation of a chronic condition