Basics of Electronic Healthcare Records

Description

COURSE DESCRIPTION

This course covers the basics of medical records according to U.S. standards, including HIPAA and ADA compliance. The ICD and CPT coding relevant to acupuncturists are discussed. Navigate the Evaluation and Management (E/M) documentation in the Electronic Health Record (EHR), focusing on health history, physical examinations, and the use of functional questionnaires to monitor treatment progress in accordance with CMS requirements. Learn how to document clinical impressions, red flags, referrals, and acupuncture diagnoses in the SOAP note. Explore goal setting and the development of treatment plans. Documentation of acupuncture procedures, including identifying adverse events, is explained in detail.

COURSE LEARNING OUTCOMES, GOALS & OBJECTIVES

1. Understand ADA Compliance for Accommodation of Patients with Disabilities on the Website and Interpreter Services for Patients with Limited English Proficiency.
2. Understand the Confidentiality of Healthcare Records (HIPAA) and Electronic Health Record (EHR) Systems – HITECH Compliance
3. Demonstrate Evaluation and Management (E/M) Documenting According to the CMS Requirements
4. Reinforce Acupuncture Procedure Documentation Standards
5. Navigate SOAP Note Format of Healthcare Records

RECOMMENDED TEXTBOOKS & EDUCATIONAL MATERIALS:

1. The Traditional Medicine Clinical Practice Manual Textbook (is printed on demand, and ships directly from the publisher. Please allow at least 2 weeks for delivery.)
2. The Traditional Medicine Clinical Practice Policies & Procedures Downloadable Manual