Quick but Quality Routine Visit Documentation – Part 3

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Recorded August 28th, 2014 View Webinar

Kathy-Mills-Chang-100x150Join our special guest Kathy Mills Chang, MCS-P—documentation expert and founder of KMC University in this third of a three-part series on documentation.Your day to day, routine visit documentation, or that documentation of the “non-evaluation and management” visits, should tell the story of the patient’s progress under your care. While comprehensive, they daily note doesn’t have to be difficult to complete. This session will outline the requirements of the daily note, whether third party, cash, or wellness. Learn how the better the work done on the initial, foundational visit for the episode of care, the more streamlined the daily note, saving time but ensuring complete and accurate documentation.

Learning Objectives and Program Goals:

  • Understand how the initial visit of an episode or burst of care will establish the outline for the day to day visits, and the tracking of progress and treatment provided.
  • Name all the components of day to day documentation requirements from active episodes of care to maintenance and wellness visits.
  • Complete the fundamentals of Subjective, Objective, Assessment and Plan in a daily note, using the “set up” from the initial visit in that episode of care for guidance.
  • Compose a daily, routine visit note that contains Subjective and Objective components for each region of the spine treated and tells the story of the patient’s progress in the doctor’s Assessment.