Awesome Documentation

Overview

Documentation is essentially telling your patient’s story.  You are getting to know your patient, what brings them in, what they’ve experienced in the past, and what’s going on with them right now. They have a goal (or ten ; ) and your creating the best path to get them to their goals based on their history & what you find.  Getting to know your patient is the FUN part of practice, documentation is just the recording of that interaction.  At the end of this course you will be able to make improvements to your documentation procedures to reduce charting time, improve compliance, & enhance your patient experience!

What You’ll Learn

• Create compliant documentation that works FOR you and your practice- “re-framing”
• Be able to create effective documentation that enhances your practice
• Better understand Medicare Basics
• Using your EHR to make documentation faster, easier and complete
• Be able to make improvements to your documentation procedures next day that will increase retention, referrals and revenue!
• Avoid pit falls of poor documentation and billing- stay out of trouble

Part I (1 hour)

• Purpose of Documentation: Benefits to documenting properly
• Understand basic documentation requirements and how to meet those requirements

Part II (.5 hour)

• Medicare Basics
  • Covered services vs non covered services
  • What a series of care is expected to look like
  • Proving medical necessity (for each area you treat/bill for)

Part III (.5 hour)

• Addressing the most common issues doctors have with documentation
  • Takes too much time
  • Is the least “fun” part of the job
  • “Pointless”

• Avoid pit falls of poor documentation– stay out of trouble- from my board experience-
  • Most common mistakes
  • Common audit triggers- know and how to avoid them