During the second set of examples, you will write actual notes. Learn how easy it is to document accurately using the sample templates provided. The entire group watches the video example. The templates in the workbook have the chief complaint and history of present illness written down for you. You will learn exactly how much physical exam, history, and decision-making it takes to document the correct level of service.

We then grade each other’s notes and find that most people still have put in too much of something or not enough of other things. That is perfect! This is where the real learning starts! We cover another patient. Then another. Then a new patient. Then an established patient. We practice documenting patients with no history. Other times we practice documenting notes with no exam. Over and over until everyone is an expert.

Over the next few hours of patient examples, we continue this cycle of auditing and correcting notes then writing our own. By the end of this section, usually the entire audience is comfortable writing a high-level note in 20-30 seconds. Don’t guess how to code correctly—become an expert!

Learn to recognize 99214 and 99215 patients as soon as you begin talking with them. Know exactly what is required to quickly complete your documentation and move on to the next patient.