SOAP Note Best Practices: Case Study 2 – Initial Herbal


ON DEMAND – Recorded WEBINAR        Florida 1.5 CEU 

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As healthcare providers, Licensed Acupuncturists are subject to mandatory documentation and practice guidelines. In each class of this monthly series of interactive SOAP NOTE BEST PRACTICES: Case Study webinars, we will together document an actual patient encounter. This class will navigate Initial Traditional Chinese Herbal Medicine (TCHM) SOAP. Suggested prerequisites SOAP Note Best Practices Introduction: Evaluation & Management Guidelines Webinar & Case Study 1 – Initial Acupuncture Webinars.

This class focus:

  • Brief review of necessary health data to satisfy mandatory CMS healthcare documentation guidelines
  • Discuss how to formulate a diagnosis compliant with the FDA language pertaining to TCHM Rx.
  • Select and appropriately record standardized ICD-11 Ch. 26 Traditional Medicine pattern associated with billable current ICD-10 diagnosis
  • Discuss and order Lab Work necessary for risk assessment
  • Review drug-herb interactions & identify potential Adverse Effects
  • Formulate appropriate Taiwanese-style 5:1 granule formula, including patient-specific dose calculation
  • Place a custom formula order into 3rd party compounding pharmacy and outline the FDA requirements for TCHM formula recording in the SOAP
  • Issue to the patient EHR portal homegoing instructions, including legal language pertaining to TCHM

Included in this class: Access to standardized Intake and SOAP note Templates.

Through this series of monthly interactive webinars, also we will discuss how to:

  • Identify and Formulate Chief Complaint(s)
  • Determine the accurate amount of information you must collect to support the level of Medical Decision Making
  • Assess Complaint Improvement
  • Support Medical Necessity
  • Record Patient’s Non-compliance
  • Justify the Lack of Improvement
  • Select & Record Treatment Strategy
  • Justify ICD-10 Western Diagnosis
  • Select & Record the Appropriate TM Patterns
  • Identify Appropriate Treatment Method
  • Formulate Treatment Principles based on the different Styles of Acupuncture
  • Formulate and Record an Appropriate Treatment Plan
  • Establish a Short and Long Term Goal
  • Identify Potential Red Flags and Appropriate Referrals
  • Establish Necessary Labs/Imaging to be Ordered
  • Record & Select Appropriate Acupuncture Procedure Codes and the desired Number of Units
  • Select & Record Adjunct Treatment Techniques and Procedures
  • Select & Record Supplements Prescribed Accordingly to the TCM Pattern
  • Select & Record Patent TCHM
  • Record Custom Compounded Formula from 5:1 TCHM granules
  • Legally Reopen & Amend Closed and Signed SOAP Notes

Documentation guidelines, known as Evaluation/ Management guide (EM), are routinely reviewed and amended by the Centers for Medicare & Medicare Services. The most recent revision of the EM guide was implemented on January 01, 2021. The 2021 EM guide contains significant changes which are beneficial to LAc. New guidelines were added, allowing healthcare providers to collect the clinically necessary amount of subjective data and physical examination.

With the release of the ICD-11 Chapter 26 Traditional Medicine Diagnostic codes in standardized terminology.  Licensed Acupuncturists, as a profession, are making the first grand step towards worldwide acceptance as a healthcare profession, not only as an acupuncture procedure service. The ability to make an independent diagnosis moves us from a technician performing the acupuncture procedure to a diagnosing clinician category, subject to physician-level regulations and reimbursement. (Do Not Mistake this with the legal scope of practice of your State)

You are welcome to present your case for discussion in the subsequent webinar.

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