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Naturopathic Doctor

Documentation 161

Keys to Clinical Documentation


  • Recognize the key components regarding good documentation and record keeping
  • Identify the legal requirements of informed consent and the key elements of the informed consent process
  • Discuss why doctors are held to higher standards
  • Describe the 21 NCQA guidelines for record keeping
  • Document progress notes (SOAP) to meet insurance guidelines and medical necessity
  • Apply the PARTS system and its transformation utilizing a new method AIR S & M
  • Utilize CMT coding appropriately
  • Utilize E/M (Evaluation/Management) coding appropriately to meet insurance guidelines and medical necessity
  • Identify the 3 categories and 2 subcategories of E/M codes
  • Identify the 5 levels of E/M services for new and established patients
  • Identify the 7 components (descriptors) used to determine the level of E/M service
  • Select the appropriate level of E/M services utilizing 7 simple steps

Paul Sherman, DC

AudioVisual Course

$40.00 USD

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