CLINIC – Traditional Medicine Clinical Practice POLICIES & PROCEDURES Manual.

Description

Downloadable and customizable CLINIC – Templates, Policies, and Procedures for your practice.

Clinic Policies & Procedures Manual

• Healthcare Records Policy ……………………………………………………………………………….….… 2
• Documentation Standards Policy ………………………………………………………….……………..……. 7
• Encounter Note Documentation Procedures …………………………………………………………………. 10
• Missed Appointment Documentation Policy & Procedures …………………………………………………. 16
• Coordination of Care and Referral Policy & Procedures ……………………………………………….……. 17
• Patient Education Policy & Procedures …………………………………………………………………..…… 18
• Lab/Test Ordering and Tracking Policy & Procedure ……………………………………………………..…. 19
• Patient Draping Policy & Procedures ………………………………………………………………………..… 21
• Infectious Epidemic Disease Reporting Procedure ………………………………………………………….. 23
• Abuse Reporting Procedures ………………………………………………………………………………..… 24
• Quality Assurance – Internal Audit Policy & Procedures ………………………..…………………….…….. 25
• Workforce Training Plan ……………………………………………………………………………….……..…. 26

Clinic Templates Manual

1. Personal Information Form ….. 2
2. Initial E/M Health Info EHR Questionnaire – for Acupuncture Encounter ….. 3
3. Initial E/M EHR SOAP Note – for Acupuncture Encounter …. 6
4. After Visit Summary for Initial E/M – for Acupuncture Encounter …. 9
5. Follow-Up E/M Health Info EHR Questionnaire – for Acupuncture Encounter …. 10
6. Follow-Up E/M EHR SOAP Note – for Acupuncture Encounter …. 13
7. Follow-Up Acupuncture Encounter Health Info EHR Questionnaire …. 16
8. Follow-Up EHR Acupuncture Encounter SOAP Note …. 17
9. Acupuncture Procedure ….. 19
10. After Visit Summary Acupuncture Procedure …. 20
11. Initial E/M Health Info EHR Questionnaire – for TCHM Encounter ….. 21
12. TCHM Initial E/M SOAP Note ….. 24
13. TCHM After Visit Summary ….. 28
14. Follow-Up E/M Health Info EHR Questionnaire – for TCHM Encounter ….. 29
15. TCHM Follow-Up E/M SOAP Note ….. 32
16. TCHM Prescription SOAP Note Record Templates … 36
17. Pain Assessment Questionnaire …. 37
18. ADL/IADL Evaluation Modified Questionnaire ….. 38
19. Hot Flash-Related Daily Interference Scale (HFRDIS) …. 39
20. Quick DASH (Upper EXTREMITY) ….. 40
21. Lower Extremity Functional Scale (LEFS) ….. 42
22. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) ….. 44
23. Knee Injury and Osteoarthritis Outcome Score (KOOS) LONG …. 45
24. Modified Oswestry Low Back Pain Disability Questionnaire ….. 47
25. Neck Disability Index ….. 49
26. Fibromyalgia Impact Questionnaire (FIQ) ….. 51
27. Headache Disability Index ….. 52
28. Pittsburgh Sleep Quality Index (PSQI) ….. 53
29. Hospital Anxiety and Depression Scale (HADS) ….. 55
30. Information Sheet on IBS – Quality of Life Measure (IBS-QOL) ….. 56
31. Acupuncture Letter of Medical Necessity …. 58
32. Letter of Medical Necessity for TCHM to FSA or HAS …. 59
33. Audit Worksheet – 2021 E/M Office or Other Outpatient (99202-99215) …. 60
34. Acupuncture Procedure Audit …. 64
35. Internal Audit LOG ….. 65
36. VA Pain Scale Handout ….. 66
37. Personnel Training Log – IS LOCATED IN THE EMPLOYEE MANUAL