SOAP notes are one of the most important things to get right in chiropractic care. Not only does it inform how you treat your patients, but it affects your ability to get reimbursed by insurance as well. While Platinum makes SOAP notes easy, you can still run into problems if you don’t do them just right.
SOAP stands for subjective, objective, assessment and plan.
- Subjective: these are qualifiable and descriptive, and include how your patient describes how he feels and how the pain started. It can include direct quotes from your patient. These notes are from the patient’s perspective.
- Objective: This section of your notes should be measurable, and includes things like vital signs and all testing performed.
- Assessment: This is where you assess and document your thoughts on the patient’s treatment plan and problems. It should include the diagnosis and prognosis.
- Plan: This includes your treatment plan and what comes next. You can include short-term and long-term goals as well as any changes that come up during the course of treatment.
Here are five ways you may be doing your SOAP notes wrong.
1. Not using templated questions
Platinum offers pre-determined subjective SOAP notes to help you do them quickly. The purpose is to save chiropractors valuable time and money. Your first round of questions with a new patient will take longer than future ones.
The ideal SOAP note:
- Includes notes that are easy to understand, follow a system, and are very descriptive
- Includes documentation of the patient’s progress
- Uses accurate codes
- Focuses on quantity over quality
- Provides the specifics that Medicare requires
- Is detailed
Because it’s so important to get these right, don’t skip templates for your questions.
2. Making mistakes on documentation
Faulty documentation can land you in trouble, especially when it comes to Medicare reimbursement. Medicare’s denial rate is between 60%-100%, depending on the practice, and a lot of that comes down to documentation. It’s a shame to miss out on revenue due to something that can be so easily fixed.
A decade ago, Medicare required that you document the patient’s level of pain. That changed, though, and it’s no longer enough. You must document their level of pain prior to and after treatment, and treatment has to be medically necessary. You should note what they were not able to physically do prior to treatment, and how those specific things have improved.
Platinum’s screens are customizable, so you can set up subjective questions and make sure that all the required information is filled out and easily accessible.
3. Waiting until the end of the day
If you see multiple patients a day, avoid waiting until the end of the day to do your SOAP notes. Document them as you’re seeing the patient so that you don’t forget crucial information and waste valuable time. Don’t let your documentation be an afterthought.
The more mainstream chiropractic care becomes, the more scrutinized the care is by insurance providers. And it’s your notes, which serve as the patients’ record, that get scrutinized. Make SOAP notes a part of your routine with every patient visit so that the thoughts are fresh on your mind and nothing falls through the cracks.
4. Not asking the right questions
SOAP notes aren’t just about staying in compliance or documenting treatment plans. They can also protect you against a malpractice suit or to justify charges. It’s much easier to defend your actions and defend your case if you have lots of documentation!
Be sure to include the following in your chiropractic SOAP notes:
- The patient’s level of pain
- The location of the pain
- Whether the pain is intermittent or constant
- Results of testing
- You treatment plan
5. Not documenting your treatment plan
If another chiropractor had to take over the treatment of your patient, would they be able to do so based on your SOAP notes alone? If the answer is no, your notes aren’t thorough enough.
Your treatment plan, documented in your SOAP notes, should include:
- All the tests performed and their results
- The expected duration and frequency of your patient’s visits
- Any advice you’ve offered, whether that’s related to lifestyle or nutrition
- Exercises you’ve advised
- A timeline
- Massages, chiropractic manipulative therapy and
- Suggested modifications to daily living
How Platinum helps chiropractors with SOAP notes
As we mentioned above, Platinum offers templates for SOAP notes, which saves you time, energy, and money. Our software was designed by chiropractors in an actual practice, and so we know the ins and outs of chiropractic care.
If you want to streamline your SOAP notes and shave minutes off of every patient appointment, talk with us today!