Documenting the Treatment Plan (2 CE DOC)

Instructor: Dr. Evan Gwilliam, DC, MBA, BS
Certified Professional Coder, and Certified Professional Medical Auditor – CPC CCPC QMCC CPMA CPCO AAPC Fellow

This course explores essential documentation strategies for modern chiropractic practices, emphasizing self-audit practices and effective treatment plan development. Participants will learn how to create logical care plans that demonstrate medical necessity while ensuring their documentation properly supports the procedures they perform.

The curriculum covers the fundamentals of chiropractic documentation, including what constitutes an audit, how to define appropriate treatment plans with measurable goals, and guidelines for maintaining compliant medical records. Practitioners will gain valuable skills in self-auditing techniques to evaluate their own documentation practices before external reviewers do.

A systematic approach to clinical documentation is presented, focusing on effectively recording patient history, complaints, and examination findings. Participants will develop expertise in diagnostic documentation, treatment planning, and tracking meaningful patient progress through measurable metrics.

Special attention is given to essential documentation elements including care plan components, goal setting, outcome assessment tools (OATs), and specialized assessment instruments like the Oswestry Disability Index. The course, presented by Evan M. Gwilliam, DC, MBA, provides practical strategies for creating treatment documentation that meets professional standards while demonstrating the value of chiropractic care through measurable patient outcomes.

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