Keep Your Records Clean With SOAP

This section is compiled by Frank M. Painter, D.C.
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FROM:   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:

1.   To defend yourself against a malpractice suit;
2.   To justify your charges in a third-party payer audit;
3.   To track your patients’ progress; or
4.   By medical doctors only.

The correct answer?

1, 2 AND 3.

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.”

“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.

Subjective:   This covers the patient history, including the review of intake forms. “Whatever the patient tells you about his complaint belongs here,” says McClelland. “Where is the pain? Is it focused, or does it radiate? Is it intermittent or constant? They’re telling you this. It’s not what you’ve found on an examination, so it’s subjective.”

Objective:   This is your record of the physical examination portion of the patient encounter, including the results of any laboratory and imaging tests that may be performed.

Assessment:   This is your diagnosis, as well as your assessment of progress.

Plan:   This is your plan of care. It includes not only your initial treatment plan (expected duration and frequency of care along with recommended services, including any possible additional testing, etc.) but on subsequent visits, the treatment rendered on that encounter, home recommendations, referrals to other providers, etc. It should also include the patient’s response to the treatment (i.e., patient tolerated manipulation well and reports pain has reduced from a 6/10 to a 3/10).

The SOAP note for your initial encounter with a particular patient will usually be significantly longer than notes for follow-up visits, says McClelland. “In your first visit, the ‘S’ will include the full patient history,” she explains. “For subsequent visits, the ‘S’ will be an update and include anything the patient reports to have changed since your last encounter. Maybe the pain was radiating as far as the lower leg, and now it’s only to the knee. Or maybe the patient fell down the steps and aggravated a prior injury. Similarly, for the objective portion, you won’t repeat the full range of tests you did on the initial visit, but you’ll do a brief exam in the area of treatment to see how the findings correlate with what you were told.”

There is no question that good SOAP notes can be a lifesaver in malpractice litigation or third-party auditing. “I’ve probably reviewed 100 malpractice cases over the past decade, and one of the most problematic areas is poor documentation,” says Dr. Hamm. “It’s much easier to defend a case that has good records.”

Enhancing Quality of Care

But that’s not the primary purpose of the note. “It’s a nice benefit, but the purpose of SOAP notes is to have a record of the patient’s care in order to enhance the quality of care you give now, and to aid when future care may be needed,” says McClelland. “You are not going to be able to remember, visit-to-visit, all the details of the last time you saw the patient. You need a record to be able to track the patient’s progress, or lack thereof, and see when a change in protocol may be called for.”

The most common mistake made by doctors of chiropractic in SOAP documentation is lack of patient- and encounter-specific information, McClelland says. The note is not about quantity, it’s about quality. “You can have a very short note that has all the information you need, and a three-page note that has none of the information you need.”

For instance, McClelland describes one doctor’s SOAP note that took many paragraphs to essentially state the following: “Patient had pain with referral and spasm.”

“It told you absolutely nothing,” she says. “Where was the pain? How did it start? When did it start? Was it constant or intermittent? If it was low-back pain, did it radiate down the leg? Was the foot numb?” Instead, she says, proper SOAP documentation of a chief complaint might read something like: “Patient presented with severe lower back pain, with referral down the posterior left lower extremity to the ankle.”

“Over the next few visits, if the assessment now describes moderate low-back pain with referral down the posterior left leg to the knee, we can see that pain is less and the referral is less, so the patient is improving,” she says. “Without this kind of detail, there’s no way to evaluate the effectiveness of treatment.”

Another common error in chiropractic documentation, McClelland says, falls into the “P” (or Plan) section. “Some providers don’t actually note that they adjusted the patient, or whatever services they performed. They’ll record their objective findings, such as subluxations or joint fixations, but then they will never actually state in the note that they adjusted those areas. They feel that the findings imply that they did, but you have to document you actually did it!”

Some providers use a pre-formatted checklist to help them organize their SOAP notes, but Dr. Hamm says that can be a pitfall in itself. “They can include a long list of orthopedic and neurologic tests, which may or may not have meaning in that patient’s case,” he says. “The doctor can get bogged down in tests that may not be relevant. I think the best note is written on a blank sheet of paper or computer screen.”

One tool that can make SOAP documentation easier for the pen- or keyboardweary doctor of chiropractic is voice-recognition software. Dr. Hamm has been using Dragon Naturally Speaking’s medical version, which added a chiropractic vocabulary in its latest release, for about a decade.

“For a new patient, if it’s an uncomplicated case, I can dictate a SOAP note in under five minutes,” he says. “On a subsequent follow-up visit, it would probably take 1 to 2 minutes or less, unless there are multiple complaints.”

“I also believe that the Cadillac of documentation is dictation,” McClelland agrees. “Most doctors of chiropractic cannot afford transcriptionists; however, voice recognition solves that problem. Dictation will vastly increase the chances that your note will be patient- and encounter-specific. And many of today’s certified electronic health records will accept entries through voice-recognition software, giving you the best of both worlds.”

The Dead Doctor Rule

To help gauge if you’ve written a good SOAP note, McClelland says, apply the “dead doctor” rule: “If you get run over by a truck tomorrow, could another doctor, walking in with no idea of what’s going on, understand what’s wrong with the patient, where they are in their progress, and so on? That’s a measure of good documentation.”

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