As healthcare providers, Licensed Acupuncturists are subject to best practice standards and documentation.
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.
In this monthly series of SOAP NOTE BEST PRACTICES, each class will provide real-life examples of SOAP notes, write together as a class SOAP notes (you are welcome to present your current case for discussion in the subsequent class), and we will also 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 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
Included in this class: Access to standardized Intake and SOAP note Templates.
You are welcome to present your case for the discussion in the subsequent webinar.