Patient Triage, Coding & Documentation

3 CE’s

* CE Credits are for Doctors of Chiropractic only

** No CE available in CA, WV.

Triage & Collaborative Care Planning

Clinical Evaluation + Advanced Imaging + Electrodiagnostics for Real-World Patient Decision-Making

When a patient presents with pain, weakness, neurologic signs, or complex comorbidities, your next steps must be accurate, defensible, and clearly documented—especially when imaging and electrodiagnostic testing complicate the clinical picture.

This program equips you with the practical skills to interpret clinical evaluation findings, correlate them with advanced imaging and electrodiagnostic results, and recognize comorbidities that change patient risk, treatment strategy, or referral urgency. You’ll learn how to build a clear triage pathway and create collaborative care plans that support both clinical outcomes and documentation integrity.

Designed for immediate use in practice, this training helps you confidently determine:

• Who can be treated in-office

• Who requires triage out of your office

• Who needs co-management or referral

• How to document why your decisions were medically necessary

What You’ll Be Able to Do After This Course

By the end of this program, you will be able to:

✅ Identify clinical findings and comorbidities that drive triage decisions
✅ Correlate symptoms with MRI, testing, and neuro findings with confidence
✅ Differentiate radiculopathy vs. myelopathy—and recognize serious cord pathology
✅ Document the demonstrative cause of pain in a way that is clear to patients and carriers
✅ Apply ICD-10 coding strategically for long-term care needs when comorbidities exist
✅ Create a defensible care path that includes triage, referral, and collaborative care

Program Objective

To document specific comorbidities, conclusively establish the demonstrative cause of the patient’s pain, and create a care path that includes triage and collaborative care when clinically indicated.

Expected Learner Outcome

Participants will be able to triage and diagnose both trauma and non-trauma cases while ensuring documentation supports medical necessity and long-term care planning.

Course Modules (3.5 Hours Total)

30 Minutes — Evaluation & Management Documentation Guidelines

Triage starts with the clinical evaluation.

You’ll learn what to look for in the E/M process, including:

• Red flags and direct findings that require escalation

• How to identify and document comorbidities that influence triage decisions

• Documentation essentials that support medical necessity

Outcome: You’ll improve the defensibility of your clinical findings, not just your note-taking.

60 Minutes — Clinical Findings + Required Documentation for Patient Triage

This module focuses on the practical clinical and documentation elements that determine whether a patient should be:

• Triaged out of your office

• Managed directly

• Co-managed with a specialist

You’ll cover:

• Diagnosing and documenting clinical findings with precision

• Matching exam findings to imaging and diagnostic results

• Identifying comorbidities that change treatment appropriateness and risk

Outcome: You’ll build a repeatable process for making triage decisions supported by documentation.

30 Minutes — Imaging & Testing Needed to Correlate Clinical Findings

MRI findings alone are not enough—correlation is everything.

You’ll learn how to interpret:

• Common spinal pathology patterns on MRI

• Systemic, metabolic, or underlying issues that alter treatment planning

• How to finalize a treatment plan using both clinical and imaging data

Outcome: You’ll avoid “imaging-only” decision-making and strengthen clinical justification.

60 Minutes — Radiculopathy vs. Myelopathy: Cord Edema vs. Myelomalacia

This module trains clinicians to recognize the difference between findings that are urgent, progressive, or permanent.

You’ll learn:

• Radiculopathy vs. myelopathy: what differentiates them clinically and radiologically

• Cord edema vs. myelomalacia: what it means for prognosis and care urgency

• ICD-10 coding strategies that support long-term care needs in cases involving comorbidities

• How to write reports that make complex findings understandable to:

  • Patients

  • Carriers

  • Third parties

You’ll also learn how to triage incidental pathological findings on imaging—without missing what matters.

Outcome: You’ll be able to clearly document severity, permanency risk, and necessity for collaborative care.

Who This Course Is For

This program is ideal for clinicians who manage patients with:

• Spine pain with neurologic symptoms

• Complex imaging results

• Systemic or metabolic comorbidities

• Trauma and non-trauma presentations

• Cases where documentation must support triage, co-management, or referral

If you want a repeatable system for triage decisions, documentation clarity, and defensible collaborative care planning—this is built for you.

Instructors 

Mark Studin, DC, FPSC, FASBE(C), DAAPM
Don Capoferri, DC, FSBT, FPSC

This course is led by recognized clinical educators with extensive expertise in spine-based triage, trauma and non-trauma diagnosis, documentation strategy, and interdisciplinary care planning.

Ready to Strengthen Your Triage Confidence + Documentation Defensibility?

Learn the clinical interpretation and documentation strategies that help you triage accurately, protect patients, and communicate findings clearly—without guesswork.

Enroll now to gain immediately applicable skills you can implement with your next complex case.

Instructions: Once you purchase the course online, it will be immediately active in your account. If you have any issues, please contact Cara 631-804-2845 or CaraRoss220@Gmail.com