Keep Your Records Clean With SOAP
SOURCE: ACA News ~ November 2013
By Gina Shaw
If you are asked what a SOAP note is used for, what would be your answer? A SOAP note is used:
3. To track your patients’ progress; or
4. By medical doctors only.
The correct answer? 1, 2 and 3.
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There are many systems used by health care professionals to track patients’ progress, but SOAP is probably the most common format for maintaining progress notes. Using SOAP to keep clear, complete, concise, accurate, patient- and encounter- specific records is not just for medical doctors. It’s one of the best ways for the doctor of chiropractic to monitor patients’ progress, as well as to maintain complete records that can be used as a defense in third-party audits or malpractice suits.
Unfortunately, says Susan McClelland of McClelland Consulting, one of the nation’s top experts on chiropractic record keeping, “a lot of providers are not documenting the necessary information, especially for Medicare. Medicare has very specific requirements about what you must have in your notes, and those requirements really don’t differ a lot from what today’s standard of care demands.”
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“SOAP notes have been in use in chiropractic now for about the last 20 years, but we still have a number of practitioners who don’t use them properly,” says Tony Hamm, DC, ACA vice president, who practices in Goldsboro, N.C. “People often say that it takes too much time and takes away from seeing patients, and that they don’t get paid that much to do documentation.”
But in reality, says Dr. Hamm, you are getting paid to maintain progress notes. “When a CPT code, like an exam procedure, is billed, there is a postservice component that is part of the value of the code, and that includes documentation,” he says. “It’s built into the relative value (RV) of the service itself. If that weren’t built in, we would actually get paid less for that service. Most people probably don’t realize that.”
Defining SOAP
So if you’ve been skimping on your SOAP notes, it’s time to scrub up. SOAP is a simple mnemonic, which stands for Subjective, Objective, Assessment and Plan.
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Good article. In my 21 years of practice, I have tried to improve my documentation and follow guidelines as much as possible. New practitioner’s should realize there is no “perfect” documentation.
Are you aware of any examples of good documentation from any source? I’ve seen what I thought was really good documentation get denied completely by a reviewer. How does a doctor challenge an un-credible reviewer?
Hi Dr. Johnson
As Susan mentioned in the article, following Medicare’s protocols for documentation should be more than sufficient for any genuine reviewer.
If someone is unreasonably denying care, I would file a complaint with your State Insurance Commission. Insurers HATE that, because, at least here in Illinois, it’s published.
You should also file a complaint with your State Chiropractic Association, and ask them for help. If that Company is playing games with other DCs, that could add up to a class-action lawsuit. Unless you advise your Association, nothing will ever change.