Download Reference Documents The reference documents for this module encompass multiple practice guidelines, definitions, and documentation requirements. Please note that some of these resources are in other courses in this module as they have relevance to more than one aspect of the various parts of documenting an initial visit note, periodic re-evaluation, and discharge exam….
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Download Support Tools These are documentation samples of the components necessary for a periodic re-evaluation to be noted in the patient medical record. In the sidebar you’ll find the reasoning for the individual pieces needed to create the best possible written account of how the patient in progressing. These re-evaluation documentation examples offer various formats…
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Proper Use of the Patient Progress Interview One of the most important aspects of the periodic re-evaluation is helping patients see the progress they’ve made with their function and pain relief. It’s an opportunity to not only collect the history as required for the E/M service, but also to point patients toward the improvements they’ve…
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Download Support Tool This Support Tool provides a snapshot of the thought process that occurs when the doctor is establishing the CPT codes to be billed via the documentation; the treatment plan is a vital step in that process. Documentation Drives Coding
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Download Reference Documents The first two resources listed here are neck and low back diagnosis tables pulled, with permission, from the Sousa textbook. Refer to these tables to ensure your doctoring is leading to the most accurate diagnosis codes and that you have the findings to verify the codes you are using. In the third…
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Download Reference Documents The following Reference Documents are tools for you to review as you move through this exam documentation module. The first two resources are easy-to-reference lists that will help you brush up on several common orthopedic tests used during chiropractic examinations. The next two reference documents cover the rules as they apply to…
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