Physicians and therapists must produce clinical documentation in increasing volumes and detail to ensure the best medical care, pay medical claims in full and on time, and protect the practice from post-payment audits and unfair litigation.
But the speed of documenting visits conflicts with the accuracy and completeness of the documentation. For insurance companies, documentation of the patient’s visit must be accurate and complete. If the quality of documentation is high, medical billing appeals on unpaid claims are paid faster and at a higher rate. Otherwise, appeals are denied and the practice becomes vulnerable to post-payment audits, refunds, and penalties.
Insurance companies don’t care how long it takes to produce good documentation. But for the provider, slow documentation impedes the profitability of the practice and wastes valuable time. Documentation of the visit must be completed by the physician at the time the patient leaves the office.
To ensure comprehensive note coverage, the healthcare industry took a structured, two-pronged approach. First, the clinician uses the SOAP note format, which reflects four key stages of patient care, from subjective observations to objective symptoms, diagnostic evaluation, and completion with the treatment plan:
- SUBJECTIVE: The initial part of the SOAP note format consists of subjective observations. These are symptoms typically expressed verbally by the patient. They include descriptions of the patient’s pain or discomfort, the presence of nausea or dizziness, or other descriptions of dysfunction.
- AIM: The next part of the format includes the symptoms that are actually measured, seen, heard, touched, felt or smelled. Objective observations include vital signs such as temperature, pulse, respiration, skin color, swelling, and diagnostic test results.
- ASSESSMENT: Assessment is the diagnosis of the patient’s condition based on subjective observations and objective symptoms. In some cases the diagnosis may be a simple determination while in other cases it may include multiple diagnostic possibilities.
- PLAN: The last part of the SOAP note is the treatment plan, which may include laboratory and/or radiological tests requested for the patient, medications requested, treatments performed (eg, minor surgical procedure), patient referrals (referral specialist), disposition (eg, home care, bed rest, short- and long-term disability, days off work, hospital admission), instructions for the patient, and follow-up instructions for the patient. patient.
Below, each of the four key SOAP stages consists of templates that reflect multiple possibilities for each stage. The templates, arranged in SOAP order, ensure comprehensive coverage and allow the clinician to simply check multiple on-screen checkboxes prompted by a software program.
The templates have drawn two criticisms from both the provider and payer side. Providers don’t like the lack of built-in intelligence to reflect individual physician preferences in treating patients. Notes generated by templates are often suspected by payers to be of low quality and poorly reflect the patient’s actual condition and treatment progress due to the template’s susceptibility to mechanical clicks and difficulty of interpretation.
The challenge is to combine the benefits of the template and detailed formats without its drawbacks to describe a patient’s accurate condition, ensure productive medical billing, prepare for regulatory scrutiny, and improve practice productivity. To overcome the perception of machine-generated notes and save the clinician time typing, some vendors have created specialized products that use random wording for each template. Such automatically generated notes include sentence structures, which closely resemble natural speech patterns.
Flexibility and integration should be key design features of SOAP notes. In the opening section, for example, you create new patient files that grow organically with each visit or treatment. Built-in intelligence allows you to customize a document to your own preferences and see all of the patient’s progress history on a single screen. Native system integration with medical billing systems enables automated claims generation, validation, and submission to payers for payment.
SOAP notes should not simply emulate the paper folder every doctor has for every patient. They must use information technology to help automate routine tasks and create a faster, easier, and error-free process to increase practice profitability and reduce audit risk.