SOAP Note Best Practices Introduction: Evaluation & Management Guidelines

Course overview

This class will introduce new guidelines for Evaluation & Management (E/M) visits effective 01/2021. We will navigate how Medical Decision-Making affects practice of ancient medicine in the modern world. This class presents the TCM practitioner viewpoint for note-taking, enhances the efficiency of TCM clinical practice, and facilitates the accuracy of TCM pattern differentiation diagnosis. COURSE LEARNING OUTCOMES: Through the successful completion of this course, each student will be able to: Understand the importance of Medical Decision Making (MDM). Understand and apply MDM Elements for most effective time management. Select appropriate Evaluation and Management (E/M) visit CPT Code, specific to acupuncture or herbal service. Determine level of subjective and objective data necessary to support the diagnosis. Identify elements of Assessment that justify medical necessity. Learn how to think on paper. Parallel current ICD-10 and/or future ICD-11 billable diagnosis to NON-billable Traditional Medicine (TM1) pattern diagnosis. Understand and apply legal language in SOAP. Formulate and reassess treatment goals. Learn proper recording of administered treatment, Learn proper recording of home going instructions, recommendations, ordered labs, and referrals. Explore in details real SOAP notes.