SOAP Notes Study 1

Course overview

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. With the release of the ICD-11 Chapter 26 Traditional Medicine Diagnostic codes in standardized terminology; As a profession, Licensed Acupuncturists are making the first grand step towards worldwide acceptance as a healthcare profession, not only as an acupuncture procedure service. The ability to make our own diagnosis moves us from a technician, who performs the acupuncture procedure, to a diagnosing physician category on the clinical level. (Do Not Mistaken this with the legal scope of practice of your State) 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: When to use E/M SOAP Notes (acupuncture/Herbs) versus Acupuncture Procedure notes Focus on differences in Subjective and Objective data collection necessary for herbal versus acupuncture SOAP Highlight differences between legal language to mitigate the risk necessary for Herbal encounters, including telehealth versus Acupuncture. Discussion of how TCM pattern changes depending on the problem addressed Reinforcement of FDA-compliant language related to Herbs/Supplements recommendations Best practices for Herbal Rx 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.