Evaluation & Management (E/M) Documentation

Precision Documentation. Compliant Coding. Defensible Care.

12 Credit Hours

Why This Course Matters

In today’s regulatory, payer, and medico-legal environment, how you document is just as important as how you treat.

The Evaluation & Management (E/M) Documentation Course has been strategically engineered to give Doctors of Chiropractic—and Medical Doctors—the clinical clarity, documentation confidence, and billing defensibility required to properly support every level of care delivered.

This is not theory.
This is real-world, audit-resistant documentation designed to withstand scrutiny from payers, attorneys, and regulatory bodies.

Who This Course Is For

• Doctors of Chiropractic

• Medical Doctors

• Providers involved in PI, Workers’ Compensation, Medicare, Managed Care, and Fee-For-Service cases

One documentation system.
One standard of care.
All financial classes covered.

What You Will Learn

This program teaches you how to accurately document:

• Initial evaluations

• Re-evaluations

• Subsequent visit encounters

—all while aligning documentation with the exact E/M code billed.

You will learn how to:

• Tell the clinical story of the patient

• Document at an academic and defensible standard

• Meet required elements without over- or under-documenting

• Protect yourself in audits, reviews, and legal challenges

Course Modules

Module 1 – Foundations of Clinical Documentation

Learn why documentation is the cornerstone of defensible care.

• Clinical storytelling and medical-legal implications

• Documenting co-morbidities, pre-existing conditions, family & social factors

• Handwritten notes vs. EMRs

• Academic-level documentation standards

Module 2 – Chief Complaint, History & Physical Examination

Master the building blocks of compliant E/M encounters.

• Chief complaint formulation

• History of present illness (HPI)

• Review of systems (ROS)

• Past, family, and social history (PFSH)

• Physical examination components:

  • Observation

  • Palpation

  • Percussion

  • Auscultation

Module 3 – Coding & Spinal Examination

Understand exactly what supports compliant billing.

• E/M codes 99202–99205 & 99212–99215

• Required elements by coding level

• Extensive review of systems

• Cervical & lumbar anatomy

• Basic orthopedic and spinal testing

• Vertebral-basilar circulation assessment fundamentals

Module 4 – Neurological Evaluation

Perform and document a complete neurological examination with confidence.

• Motor and sensory evaluations

• Reflex arcs explained

• Wexler Scales (upper & lower extremities)

• Upper vs. lower motor neuron lesion testing

• Comprehensive extremity neurological exams

Module 5 – Documenting Visit Encounters (SOAP Notes)

Turn daily notes into clinically correlated, defensible records.

• SOAP note structure and strategy

• Correlating symptoms, findings, diagnosis, and treatment

• Modifying treatment plans appropriately

• Documenting collaborative care

• Integrating test findings between evaluations

Module 6 – Case Management & Treatment Orders

Create treatment plans that reflect clinical reasoning—not templates.

• Documenting manual and adjunctive therapies

• Short-term vs. long-term goal setting

• Referrals for collaborative care and diagnostics

• Prognosis documentation

• Determining and documenting MMI (Maximum Medical Improvement)

Course Objective

To enable the doctor to create a clinically accurate, defensible Evaluation & Management document that fully supports the coding level billed—every time.

Instructors

Mark Studin, FPSC, DC, FASBE(C), DAAPM

Chiropractor
International authority in documentation, risk mitigation, and medico-legal education

Michael Barone, DC, DISCN, DIBE

Chiropractor
Expert in neurological evaluation, diagnostics, and clinical compliance

Bottom Line

If your documentation:

• Doesn’t clearly justify the code billed

• Can’t withstand audit or legal review

• Fails to tell the patient’s full clinical story

—you are exposed.

This course gives you the structure, strategy, and confidence to document correctly, compliantly, and defensibly across every payer and practice model.

Ready to elevate your documentation—and protect your practice?