Appropriate Documentation

In this timely, fast-paced session, we'll cover all the important aspects of Initial Assessment, the most important and often missing component of documentation. Documentation of the initial assessment is often confused with the diagnosis of the patient's condition. We'll cover why this mistake leaves medical record documentation lacking in the most important aspects of "doctor thinking". When these essential initial assessment components are missing, it's difficult to clarify the doctor's case management goals for the episode of active treatment. This "doctor thinking" is often conducted between the doctor's ears and not in the record, and so the lack of the initial assessment in your record can derail your best efforts at good documentation.This course was presented in May 2016 Becky Walters, MCS-P and sponsored by KMC University.

• •Understand the critical distinction between initial assessment documentation and diagnostic documentation
• •Identify the essential components of a complete initial assessment that demonstrate clinical decision-making
• •Recognize how inadequate initial assessment documentation impacts case management clarity and treatment justification
• •Learn how to properly document clinical thinking and reasoning processes to support chiropractic care episode management
• •Discover how complete initial assessment documentation strengthens medical records defensibility and case presentation