Posted by Team KMCU on Sep 4, 2023
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SOAP Documentation:
Prevent Financial Consequences
Many doctors have invested thousands of dollars in an EHR system loaded with templated macros used to create their patient records. Meanwhile other providers take their notes home with them either physically or mentally, worrying because the notes are not completed, or not sure if the documentation is compliant enough. We can all agree that what matters most is the actual information written in the encounter notes. Unfortunately, when providers jump in the third-party payer pool, and their SOAP documentation contains errors or is insufficient, there may be major financial consequences when an audit reveals that the patient records do not support the medical necessity of the services provided. It is crucial that practices employ the same high standards for documentation as they do for patient care!
Because SOAP notes are so routine and are created in such high volume daily, their importance tends to be overlooked. These notes carry a lot of weight in a records review because they tell the day-to-day progress of the patient as well as provide support for any services performed and coded. This routine office visit note also informs the reader about the patient’s compliance with treatment, if the patient is on target for meeting functional goals, and how the patient is responding to the recommended care. Attention to detail is important when documenting the services provided on each visit since the notes will be compared to the billing ledger to ensure that the appropriate codes were billed. What looks like upcoding, down-coding, missing or extra charges can come from a lack of documented support in the note and when reviewed by an auditor, can create big problems whether the errors were intentional or not.
SOAP Documentation in hand with
History, Exam and Treatment Plan
What makes the use of a SOAP note so important is that it builds off what was discovered during the history and exam and incorporates the elements of the treatment plan to show a patient’s treatment progress. Once a solid treatment plan is in place, the SOAP note is anchored by that plan allowing the patient note to reflect the application of the recommended services during each encounter.
Every note should have a beginning, middle, and an end.
The SOAP format helps to keep this information organized.
S- Subjective |
| This section of the note allows patients an opportunity to let the doctor know how things have been going since the last visit. Some of the more obvious topics patients will discuss are their current pain level and their progress toward the functional goals set in the treatment plan. They may need a little guidance from the doctor to draw out additional information. This is a great place to put information about the patients’ adherence to any home exercises or dietary changes that they were asked to make. Use quotations around a patient’s direct statement as often as you can. Also state how far along the patient is into the treatment plan (Example: visit # __ of a projected ___ visits). |
O- Objective |
| This section is for the doctor to make note of any significant findings. Although it won’t be as detailed as an Evaluation and Management (E/M) service, the doctor should still report any abnormal findings. The pre-manipulation assessment will include any subluxations/restrictions that were found. There should be objective findings for each spinal region you intend to treat. Although PART is not required for each visit within an episode of care, it is advised that you use PART to document the findings that led the provider to recommend treatment in that region. |
A- Assessment |
| This may be the most misunderstood, misused, and underutilized section of the SOAP note. It should include “doctor thinking” on how the patient is progressing toward their treatment goals and if any changes should be made to the treatment plan based on the objective findings in the previous section. Be sure to include whether ongoing care is still necessary, along with details that may help a third-party reviewer best understand your patient’s current condition. If the patient has not been compliant with the recommended treatment, it is appropriate to document the reason here along with any effect this may have on the patient’s care. |
P- Plan |
| Every story needs an ending, and the Plan section of the SOAP note is where everything falls into place. Any treatment the patient received on that visit is listed here. To receive reimbursement for the adjustment provided, the specific spinal segments that were adjusted must be listed. It is not acceptable to only state the spinal regions. It is necessary to distinguish between the treatment for restrictions/subluxations that are medically necessary and those that are compensatory and cannot be billed. All therapies should be listed along with the total time spent on each treatment and the overall or total time spent on all modalities. If exercises were done in the office, specify what exercises were performed, to what region, the number of sets and reps that the patient completed, and the time spent. Also mention the patient’s response to care that day, when the patient will be seen again, and what is expected to be done on the next visit. |
SOAP Documentation and a Practice’s Financial Health
Documentation habits often reflect the financial health and general organization of a practice. If the SOAP notes are a mess, there are almost always other shortcomings that compromise productivity and practice profitability and increase compliance risks. With the proper training and procedures in place, good documentation can be done efficiently. High-quality documentation demonstrates the doctor’s conceptual understanding of the purpose of each section of the note and that the services provided are well deserving of payment.
Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email through info@kmcuniversity or by calling (855) 832-6562.
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