2021 Got Documentation – Clinical and Practical Documentation of Chiropractic
Gregg Friedman, D.C.
4 hours of Documentation/SOAP
4 hours of California Category A/Mandatory Topic – History Taking & Physical Examination Procedures
1. Illustrate four effects of good documentation.
2. Define the Problem Oriented Medical Record (POMR).
3. Demonstrate taking a complete patient history – Onset, Provocative/Palliative, Quality, Radiating, Site/Severity
4. Demonstrate taking a complete patient history – Onset, Provocative/Palliative, Quality, Radiating, Site/Severity
5. Define the Evaluation and Management Examination for the musculoskeletal system.
6. Describe the reasons for the E/M exam.
7. Demonstrate the proper documentation of exam findings
8. Discuss the new E/M rules from Jan. 1, 2021
9. Define the concept of functional outcome assessments in clinical practice.
10. Distinguish between subjective and objective outcome assessments.
11. Describe the P.A.R.T. format of documentation.
12. Define the P of P.A.R.T. from Centers for Medicare/Medicaid Services
13. Illustrate the proper documentation of Assessment.
14. Demonstrate the proper documentation of Plan for daily visits.
15. Illustrate the proper documentation of therapeutic procedures.
16. Demonstrate the proper documentation of a treatment plan
17. Describe documenting with specific goals.
Approved For Continuing Education Credit in California, Illinois, Kansas, and Missouri. The State Boards of Colorado, Iowa, and Nebraska to do not preapprove courses, but this class meets the criteria set forth by their respective boards.