Relfexive De-Afferentation Primer Workshop

thanks for coming!

We'd like to thank everyone who upgraded their skillset for manual medicine last sunday with us at Pasig city. We trust you'll put your newfound powers for turning pain off in seconds to good use. We'll see you again soon.

Meanwhile, eyes are pointed in the direction of the third Philippine Mind-Body Convention on 19 and 20 September.

See you then and there!

Random Post #1

"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat."

- Theodore Roosevelt

PRINCIPLES OF DOCUMENTATION of MANUAL MEDICINE ENTRIES FOR CPT

PRINCIPLES OF DOCUMENTATION FOR CPT

• The medical record should be complete and legible. (Ha! Good luck with that!)

• The documentation of each patient encounter should include:
1. reason for the encounter and
2. relevant history,
3. physical examination findings and
4. prior diagnostic tests;
5. assessment,
6. clinical impression or diagnosis;
7. plan for care;
8. rationale for ordering diagnostic and other ancillary services and
9. date and legible identity of the observer.

• If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

• Past and present diagnoses should be accessible to the treating and/or consulting physician. (Good luck sourcing the following:
1. the consult sheets from the Consultants and
2. getting back the charts from the Prime Attending,
3. Junior Resident, or
4. Medical Records Gophers.

• Appropriate health risk factors should be identified.

• The patient’s treatment plan documentation should include:
1. progress,
2. response to (and changes) in treatment, and
3. any revision(s) of diagnosis(es).

• The CPT and ICD-9 codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

*Unadulterated Source: CMS and AMA publication BPO-B12, May 1997