Soap Notes

What’s in a Soap Note- Entire Series

You already know what a basic S.O.A.P. needs to have (what hurts, what do you think, what are you going to do to fix it and when to come back). You also have at least a minimum understanding of  documentation, however if we put 5 Chiropractors in a room and ask more specifically about what needs to be in the Subjective part of the note , we would likely come away with 5 different answers.

This tells us that there is quite a bit of confusion and misinformation on what specifically needs to be in your soap note for patient encounters. Proper documentation is needed for proper caring for your patients, protecting yourself from audits and malpractice law suits. While the later is rare, it still happens. Ask your malpractice rep if documentation is a major factor in their cases.

SUBJECTIVE:

The Subjective is one of the easier parts of documenting. To simplify: Why is the patient coming to see you? Now don’t get me wrong, writing just LBP or NP isn’t going to cut it.

Let’s start with an example of a proper documented Subjective complaint:

Alex came in today complaining of neck pain that started on 7/1/2010. He said, "I woke up with a stiff neck last Sunday". The symptoms are bilateral with moderate pain occurring frequently (51-75% of the day). He describes the pain as sharp and stabbing with radiating pain to his right shoulder. Ice and heat do improve the pain although the pain has remained about the same since onset and pain is rated at a 5 on a 1-10 scale (0 being no pain and 10 being excruciating). Pain is aggravated by turning his head from side to side and bending over.

In breaking this down we are covering all of the basics. You may have learned the O.P.Q.R.S.T. acronym when you were in school or at a seminar. This is a great model to stick with and actually documents above and beyond the minimum requirements.

O.P.Q.R.S.T.

• Onset- When did the pain begin?
  

• Provokes- What makes the main worse?

• Quality- Describe in the patient’s words what kind of pain they have.

• Radiates- Does the pain radiate to a body part?

• Severity- What kind of pain level are we talking about?

• Time- When did the pain start and how long has patient had condition?

Using this model is very strong. Medical documentation related to proper E&M coding requires 4 components of the HPI (History of Present Illness) be documented during the initial exam. As you can see, the above model covers 6 of them.

The same process needs to be done for all major complaints. If you prefer to treat them all at once, your initial exam and intake process will be lengthy. Another idea you may consider is to treat only 1 major condition at a time and when one complaint is at a satisfactory level for the patient, you then address the next item on their list. This reduces the documentation burden per visit and allows you and the patient to focus on one item at a time.

The history of this condition should be taken by the doctor directly. Staff does not have the proper training to recognize a risk factor so a doctor should do this portion of intake with the patient.  This is something you should keep in mind.

OBJECTIVE:

My goal with this lesson will be to show what basic aspects of the visit should clearly be documented. Anything additional you would like to include is typically alright, however I caution you to be careful when documenting exams which are not widely accepted and understood by all flavors of healthcare.

 The Objective exam can consist of many types of testing and retesting to check for differences and improvements. In this lesson I am focusing on what exams to check in a typical follow up visit.

This is a difficult lesson to teach because everyone does exams and follow-ups differently.  I will attempt to stick with the general approach to Objective exam. Objective exam is also difficult because there is no cut and dry number of items you must document to be compliant. Essentially it is very subjective since some could say simply listing ‘cervical shows stiffness’ would be the same as ‘C1, C2 and C3 on the right show stiffness today’.

Generally speaking we want to be consistent with the items we check and document here. If a patient has neck pain, we want to check ROM, swelling, stiffness, muscle tension, etc. We also want to make notes of differences for each visit and approach the documentation slightly different each time. The nature of Chiropractic is repetitive, however your job is to change this up so you don’t have 10 soap notes that all look like this: Swelling and stiffness in C1, C2 – The end.

Keep in mind that every day your notes should show medical necessity for the services you provide. There are some gray areas and you can push the envelope on extra services, however, those of you that do this often should pay extra attention to the medical necessity side of your documentation.

I want you to take away that Medicare wants you to check muscle findings along with your typical segmental areas checked. The choice is yours of course; however, briefly discussing muscles found close to a problem area of the spine is a quick and easy way to expand this area of your daily notes and improve your documentation.

Let’s see an example of a proper documented Objective below. Keep in mind I am covering just a standard follow up visit as we will cover initial exam findings in another lesson.

Palpation Exam:

Asymmetry, edema and hypertonicity were found in the upper cervical region (specifically C2 and C3 on the right side). Swelling, tautness and tenderness were also noted in right C2, C3. Motion palpable fixation, muscle spasm, weakness was found in left trapezoid muscles.

The daily Objective doesn’t have to be complicated. The challenge, as I already hit on, is how does this compare side by side against the 10 or 20 follow up visits you have between the exams? Do they all say the same thing? Are they simply a copy of the prior note? In the software notes world this can sometimes happen automatically for speed, however, you MUST change every day’s visit objective so they are not identical.

ASSESSMENT:

The days of better/same/worse are gone folks. We can no longer get by with the basics and this includes the daily assessment. What needs to be documented in order to show medical necessity in the assessment? Let’s find out.

Here is an example of a well documented daily assessment:

Diagnoses

• Lumbar Subluxation (839.20)
• Dizziness, vertigo (780.4)
• Headache (784.0)
• Neck pain (723.1)

After today's assessment Alex’s overall condition is progressing slow, but steady.

Headaches:  Patient's progress is noted as evidence by decreasing pain and increased ROM in the cervical region. Additionally Alex neck spasms and swelling are reduced.

Low Back Pain: Low back pain has been aggravated because of working longer hours on the line at work last week.

Your assessment must contain the information below every time you see the patient:

• Patient diagnosis codes.

• General daily assessment.
  
  
• Per complaint daily assessment.

I call these daily assessments because you need to change/update them each time you see the patient.

Remember the general and per complaint assessments shouldn’t be the same for every note in the patient file. Yes, changing these each time is a pain when you just saw the patient 2 days ago, however, it is the right thing to do if you want to be as compliant as possible. You need to setup your forms or software to make these quick changes. For example you should be able to change each assessment in less than 5 seconds. For my example above you would spend less than 15 seconds changing your assessment. Let’s say you see 30 patients, so it could equal 7 minutes of your time.

Now if I can help you get all your notes for that day done in just 35 minutes, I think I would make your Christmas card list.  Am I right? It can be done, however, you have to remove the extra fluff and get just the facts on progress. We will put these lessons together to share how you can accomplish a great note in less time.

PROCEDURES:

The procedure section of your daily soap is very simple. Don’t over think or over document. It only confuses the issue and makes a trained reviewer roll their eyes when they see a paragraph explaining how great Electrical Stimulation is for healing a sprained low back.

There is a lot of confusion on what must be documented per procedure performed. Your procedures should simply be a cut and dry list of what was performed with the patient during their office visit. There is no reason to write a book about the success or validity of a specific procedure. It simply boils down to what you already probably know. 

Here are a few things to consider about documenting procedures (in no particular order):

1. Does insurance commonly pay for this type of procedure, and are you using the code that you should be?
2. Does your subjective and objective note prove that the location you are doing the procedure on is valid?
3. Are you doing more procedures than really needed for this visit?

Let me break down each point above.

First, does insurance commonly pay for an item? This one is pretty common sense, but if insurance doesn’t pay for a laser treatment for fertility, then why try to get them to pay you?

Second, are you using the proper code? This is important because if you are trying to bill low level laser as a neuromuscular or manual therapy code, you are just asking for trouble. Make sure you are using the right code, and if there is no code, you should be billing as a cash procedure directly to the patient and not submitting this to insurance.

Third, the rest of your note should backup what you are doing. Your Objective section needs to mention pain or discomfort in every area if you are documenting that you did a procedure on it. A most basic medical documentation example is that if you do a strep test, you better have ‘my throat hurts’ as a subjective complaint. I like to use medical documentation examples as much as I can because in Chiropractic we seem to document completely different, and we shouldn’t. Do you think you would see a detailed description of why a strep test was performed in a medical note? Nope, this would be assumed that anyone in medical field or insurance can look up the test if they are questioning it.

Last, are you doing more than you should be doing for the patient? Let’s talk about someone going into an Emergency room. The most important thing is to find out what the problem is ASAP. That is why we spend a quick $1,000 and learn we were just dehydrated and we can return home. Stick with this idea for a moment because it applies to your patients as well. When the patient first comes in, that is when it is more ‘acceptable’ to run the most tests and have the highest patient dollar visit.

It makes “insurance sense” to focus on just one major complaint at a time.  This will of course reduce your per visit number of procedures, however, it will be more likely to get paid and will extend your patient life span of visits to your practice.

Below is an example of a simple, yet well documented daily procedures section. Keep in mind the title of your section really doesn’t matter. It could be daily treatments, treatments today, treatments, procedures, etc.

Treatments

CMT 1‑2 Spinal Regions (98940) was performed on thoracic and lumbar regions.

Neuromuscular Reeducation (97110) for 8 to 15 minutes was performed on the thoracic and lumbar regions.

Remember, keep it simple for procedures!

PLAN:

The plan section of your daily soap consists of quite a few components (or it should contain a number of important aspects).  Years ago a plan was likely to just read “return as needed” with no more details. Now that just doesn’t meet documentation standards.

While your plan doesn’t have to be complicated, it does need to have a few parts to it:

1. How often are we seeing them and what are we doing?
2. Are we doing any home therapies or home instructions?
3. What are the goals for improvement (this one is a big one today).

Ensure you cover 1 & 3 for your plan. Below is good example of how to quickly cover all three.

Plan:

• Spinal manipulation to lumbar spine 2x times per week for 3-6 weeks.

• Hot packs to lumbar region as needed to reduce swelling and improve blood circulation.

Home Therapies

To continue the use of cold and heat and the proper application of alternating cold/heat as needed for lumbar pain.

Short Term Goals

Improving low back pain to improve ability to do housework and go shopping 50% within 10 weeks.

Your assessment is where you cover your true functional improvements; however your plan should contain the goals that match the things you are also documenting in your assessment.

Make sure to match up plan items to the given condition when you are working with more than one condition. For example, if you are doing electrical stimulation for the low back, make sure you indicate that in your plan. If you just have one primary condition, this is not critical since a reviewer can see that you just have neck pain or LBP or a single condition.

Remember: plan your work and work your plan. Without a good plan your entire span of patient visits could be in jeopardy if you were to have them audited.

In our next lesson we will cover exams.

Then I will tackle re-exams, follow ups, and new conditions.

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Please stay tuned!

Thank you,

Alex Niswander

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Sources: http://www.cms.gov/  http://www.acatoday.org/

Author, Alex Niswander, is a soap notes expert with over 10 years focusing on clinical charting and proper noting procedures.  He has reviewed charts in hundreds of clinics throughout the country and continually reviews new requirements by Medicare and major insurance carriers.

To learn more about Alex’s products, please visit the company website:

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