This module will focus on healthcare records which document the immediate care and treatment of the patient and allow the physician to gauge progress. Third party payers make decisions about reimbursement based on the quality, legibility, and completeness of these notations.
An introduction to S.O.A.P. notes will be provided. The most common ways in which documentation is created will be presented. Standards of documentation required by two specific insurance companies will be described and compared. The minimal requirements for documentation within the chiropractic field will be explained.
Cervical radiculitis will be defined.
The clinical presentation which should be listed in the patient's history will be noted.
Causes of cervical radiculitis and diagnostic testing will be discussed.
Upon completion of this module,
the participant will be able to:
• Define S.O.A.P., the gold standard for daily office notations
• Describe the minimal documentation needed to process a claim
Note:
Classes are recommended for all
students but do not count towards CMP accreditation.
