The Medical Documentation Course is an online self-paced, in-depth program that focuses on patient evaluation, documentation of the encounter and its billing. Instruction is presented through self-paced videos and handouts. There is pre-, during, and post-assessment of the trainee’s documentation: pre-assessment to understand baseline, after the videos to practice learned material, and then post-course to assure there is sustained facility with documentation practices, with written and verbal feedback.

Course fee

$1,000

Availability and timeline

Self-paced, available upon request. Virtual with real-time check-ins, follow-up every two weeks for two months.

Objectives

• List common reasons for physicians’ problems with boards of medicine
• Describe appropriate documentation including clinical reasoning
• Identify essential elements of interviewing
• Describe interview practices of focused populations: family, children, adolescent, older adults (optional)
• Review coding and documentation guidelines for billing
• Describe some common legal pitfalls in patient documentation
• Document sample patient notes (pre-, during, and post-assessment)
• Review feedback received on sample patient notes (pre-, during, and post-assessment)