Description
COURSE DESCRIPTION
Module 4 of the Traditional Medicine Clinical Practice Certification (TMCPC) Program will develop HISTORY TAKING and PHYSICAL EXAMINATION competency. It focuses on Evaluation and Management documentation standards based on the Medical Decision Making (MDM) level determination, as defined by the Centers for Medicare and Medicaid Services (CMS) 2021 guidelines applicable for Traditional Medicine. Students will learn how to conduct and document a health history and a relevant physical examination in accordance with MDM requirements. Students will be able to demonstrate awareness of and familiarity with cultural competency and how cultural issues influence traditional medicine treatment and case management. Reinforce documentation of the referral to, or collaborative care with, other health professionals. Students will be able to demonstrate their knowledge of the functional questionnaires’ application. This class will exercise CRITICAL THINKING and PROFESSIONAL JUDGMENT competencies in the assessment and treatment planning. This class will advance CASE MANAGEMENT competency. Students will become proficient in collaborating with patients to develop short-term, medium-term, and long-term treatment plans, modifying plans as necessary to accommodate changes in the patient’s condition, and assessing patient outcomes. Navigate the importance of accurate documentation to ensure accurate treatment reflection for reimbursement purposes. Guidelines for documenting phone calls and no-show appointments will be introduced. Templates of the associated forms and clinic policies will be reviewed.
COURSE LEARNING OUTCOMES, GOALS & OBJECTIVES
- Reinforce Documentation Standards
- Demonstrate Knowledge of the CMS Evaluation and Management (E/M) Documenting Requirements
- Understand Medical Decision Making (MDM)
- Learn the Basics of Documentation in Clinical Practice, Including Note Types
- Master SOAP Note Elements of the Medical Decision Making (MDM)
- Learn Documenting Phone Call Communication
- Learn Documenting No-Show and Left-Without-Being-Seen
REQUIRED TEXTBOOKS & EDUCATIONAL MATERIALS:
- 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.)
- The Traditional Medicine Clinical Practice CLINIC Policies & Procedures Downloadable Manual
