SOAP Note Best Practices: Case Study 3 – ReEvaluation Acupuncture


ON DEMAND – Recorded WEBINAR      Florida 1.5 CEU


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 document an actual patient encounter together. This class will navigate Reevaluation Acupuncture SOAP. Suggested prerequisites SOAP Note Best Practices Introduction: Evaluation & Management Guidelines, Case Study 1 – Initial Acupuncture & Case Study 2 – Initial Herbal Webinars.

This class focus:

  • Brief review of necessary health data to satisfy mandatory CMS healthcare documentation guidelines
  • Discuss Outcome Assessment Tools used in the acupuncture practice
  • Discuss how to write an assessment with a focus on Functional improvement
  • Review strategies to mitigate potential Adverse Effects
  • Re-establish treatment goals if the treatment course is continued
  • Discuss referral guidelines if set goals are not achieved, or the patient’s condition worsened
  • Discuss plan changes if the patient presents with a new complaint
  • Select and appropriately record standardized ICD-11 Ch. 26 Traditional Medicine pattern associated with billable current ICD-10 diagnosis
  • Review proper Coding for E/M and acupuncture procedure
  • Navigate how to write a discharge SOAP note for the completed course of the treatment

Included in this class: Access to standardized Outcome Assessment Tools 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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