Chiropractors and office staff rely on Subjective Objective Assessment Plan (SOAP) notes not only as a way to document patient’s progress, but to also ensure accuracy in coding and billing. Quite simply, they are necessary for practical office management purposes.
Although SOAP notes have been in chiropractic use for well over 25 years now, many providers still fail to document the necessary information – especially for Medicare. So, just how well do you understand SOAP notes?
Below, we’ve highlighted the basic reasons why standardized SOAP notes are so crucial, and included the key elements that should be included in each of the four sections. If you have questions regarding this topic, or any other billing and coding issues, contact us.
SOAP Notes: The Basics
There are numerous reasons why it’s important for chiropractors and staff to standardize SOAP notes for each patient. For starters, the lack of extensive documentation can be detrimental if you are ever sued. On the flip side, thorough SOAP notes can be an asset, proving the plaintiff doesn’t have a case. In addition, SOAP notes help keep you compliant, and in case of an audit, they will prove you followed the proper procedures and billed patients correctly.
Overall, SOAP notes:
- Are used to defend yourself against a malpractice suit.
- Justify your charges in a third-party payer audit.
- Are geared toward quality rather than quantity.
- Enable healthcare providers to easily understand patient records.
- Help chiropractors easily evaluate a patient’s progress over time.
- Provide the specificity that Medicare requires.
- Help chiropractors determine how to address a patient’s complaint by way of diagnosis and treatment.
- Should include essential details, such as the exact type of pain and location.
Understanding SOAP Notes
It can be difficult to understand all the information that should be included in SOAP notes, but it gets easier when you keep in mind what each letter stands for.
The Subjective part of SOAP notes encompasses your chiropractic patient’s chief complaint and covers the patient history, including the review of intake forms. In other words, whatever a patient tells you about their complaint belongs here.
It’s subjective, because it conveys the patient’s experience of their condition, which typically includes things like back pain, neck pain, or other neuromuscular issues. Areas to consider when describing a pain history for a new patient/complaint include:
- Mechanism of Injury. How the symptoms started. Note: if the patient denies trauma, they should be questioned as to new activities and repetitive activities (work and home).
- Onset. Include the actual date of injury as day/month/year, not “last Tuesday.” If the patient cannot give a specific, then “insidious onset” should be recorded with an approximate time of initiation of symptoms such as days/weeks/months/years ago.
- Palliative/Provocative. What makes it better (palliative), and what makes it worse (provocative)? This might be things like icing, heat, bending, sleeping, moving in particular ways, etc.
- Quality. Include patient’s description of pain. For example: achey, crampy, nagging, throbbing, etc.
- Radiation or Referral. Radiating, or if not, “patient denies radiation or referral of symptoms,” or “symptoms remain local.”
- Severity. Severity of sx’s “0-4” scale “0-10” scale; pain diagram; visual analogue
- Scale Temporal Factors. Examples:
- Is chief complaint worse in the morning or evening?
- Is it constant or intermittent?
- Is it worse before or after specific activities?
- Is getting worse since onset?
- Associated with mealtimes, worse seasonally, or associated with menstrual cycle?
- Unrelated symptoms. Include associated symptoms, e.g. headaches or any other “unrelated” symptoms.
The first subjective note for a patient is generally much longer, as it contains the history elements. Subsequent subjective notes on follow-up visits should include any changes in symptoms or new symptoms, the current level of pain, how the pain has changed since the last patient visit, as well as an account of how the problem affects a patient’s daily activities and any functional improvements.
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The Objective part of SOAP includes the chiropractor’s measurable findings and data of the patient, including:
- Neurological tests
- Orthopedic tests
- Inspections of area of chief complaint, posture, gait, habitus, etc.
- Palpation of soft tissues, subluxation/intersegmental dysfunction findings
- Imaging studies
- Outcomes assessments scores
The Assessment takes into account what the doctor learns from the patient’s information and the examination performed. It includes the diagnosis and prognosis, and may also involve a differential diagnosis. When the diagnosis is unclear, the doctor should include possible diagnoses listed in order of most to least probable. This component includes a chiropractor’s assessment of the patient’s progress.
Diagnosis. This is a conclusion as to what the patient’s condition is, as gleaned from reviewing both subjective and objective data. The patient’s response to treatment (current day and overall) can be stated here as well. In regards to diagnosis, a change in severity or stage should also be noted here. For example, a change from acute sprain/strain to sub-acute sprain/strain.
Prognosis. Note impediments to recovery, ADL limitations or changes, and short- and long-term clinical/patient goals. Important note: Medicare requires the primary diagnosis be the intersegmental dysfunction/subluxation diagnosis code (739.X) followed by a secondary code from a list of diagnoses approved by Medicare for chiropractors to treat.
The Plan should communicate what the chiropractor will do to address and treat the patient’s condition. This management plan can include things like:
- Lab work ordered
- Therapeutic treatment and exercises
- Expected duration and frequency of care
- Referrals needed
- Lifestyle modifications
- Nutritional advice
- Timeline for implementation
- Types of STM, CMT, modifications to ADLs
The chiropractor should note any adjustments or other services provided during each patient visit.
It’s important for chiropractors and office staff to remember that SOAP notes need to be concise, clear and intelligible to a third party. Think of it this way: if for some reason another chiropractor had to take over and continue treatment for your patient, would they be able to do so quickly and easily by reading your SOAP notes? With clear and effective documentation, this will most certainly be the case.
We know that SOAP note documentation is tedious and can feel overwhelming and even annoying. This is an area in which ACOM Health can help. Our billing services and software not only make SOAP notes easier, you’ll have peace of mind knowing that should you ever be involved in an audit or lawsuit, your notes will be accurate and complete.
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