Overview:
  Learn specific examples how to document for services and procedures accurately and effectively. With the coming implementation of ICD-10, proper documentation will be more important than ever. This sixty-minute Webinar will provide a wealth of information concerning documentation for a wide variety of procedures and environments. 
Why should you attend: This is most important for providers and mid-level clinical professionals. Also, it is appropriate for auditors and coders responsible for translating the medical record to accurate codes.
Areas Covered in the Session:
- Basic
 
- What to avoid
 
- Acronyms and abbreviation rules and guidelines
 
- Organizational tips
 
- Illustrations
 
- Bilateral indications (especially for ICD-10)
 
- Documenting lesions
 
- Skin Grafting
 
- Burns
 
- Changes in the medical record
 
- Establishing policy concerning bad outcomes
 
- Referrals
 
- Counseling and Coordination of care
 
- Medical vs financial information
 
- SOAP and SNOCAMP
 
- History
 
- Exam
 
- Medical Decision Making
 
- Surgical procedures
 
- Documenting for complicated procedures.
 
- Surgical operative report checklist
 
- Radiological services
 
- Pathology / Lab
 
- Coding and Documentation Audit Checklist
 
- Examples and scenarios
 
- Compliance Plan
 
Who Will Benefit:
- Providers
 
- Mid - Levels
 
- Coders
 
- Coding Manager
 
- ICD-10 Implementation Team