What’s Missing from Your Documentation?
Most doctors would like to think that their documentation is bulletproof. Some have invested thousands of dollars in an EHR system loaded with bells and whistles. Others have sacrificed countless nights of sleep to write notes that are the length of a novel. Everyone agrees, however, that what matters most is the quality of the note. Unfortunately, the Office of Inspector General (OIG) says that up to 94% of chiropractic documentation contains errors or is insufficient. This can have major financial consequences if an audit reveals that the patient records do not support the medical necessity of the services provided. It is crucial that you employ the same high standards for your documentation as you do for patient care.
Because SOAP notes are so routine and are created in such high volume on a daily basis, 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. They inform 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 treatment. Attention to detail is also important when documenting the services provided on each visit since the notes will be compared to your billing ledger to ensure that the appropriate codes were billed. Upcoding, down-coding, missing or extra charges can all create problems whether the errors were intentional or not.
What makes the use of a SOAP note great 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 progress. Every note should have a beginning, middle, and an end. The SOAP format helps to keep this information organized.
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 goals set in the treatment plan. They may mention how their work/hobbies/social life have been impacted by the way they are feeling. 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. If the patient has not kept to the prescribed treatment frequency, it is appropriate to document the reason here. Also state how far along the patient is into the treatment plan (Ex: visit # __ of a projected ___ visits for acute treatment of [state diagnosis]).
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 document the findings that led the provider to recommend treatment in that region.
This may be the most misunderstood, misused, and underutilized section of the SOAP note. It should include every thought that came to mind while the doctor’s thinking cap was on. The doctor should note how the patient is progressing toward their treatment goals and if they believe any changes should be made to the treatment plan based on their objective findings in the previous section. It is also important to list any possible contraindications to care or co-morbidities that the patient has that will impact the treatment. The lack of these findings should be noted as well. 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.
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. In order to receive reimbursement for the adjustment provided, the 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, as well as the total time spent on each treatment, and the overall time spent on all modalities. If exercises were done in the office, specify what exercises were performed - to what region, the numbers 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.
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. With the proper training and procedures in place, good documentation can be done efficiently. High-quality documentation demonstrates that the doctor takes pride in his/her work and is deserving of payment for the services provided.