Keep Your Records Clean With SOAP
SOURCE: ACA News ~ November 2013
By Gina Shaw
If you are asked what a SOAP note is used for, what would be your answer? A SOAP note is used:
2. To justify your charges in a third-party payer audit;
3. To track your patients’ progress; or
4. By medical doctors only.
The correct answer? 1, 2 and 3.
There are many systems used by health care professionals to track patients’ progress, but SOAP is probably the most common format for maintaining progress notes. Using SOAP to keep clear, complete, concise, accurate, patient- and encounter- specific records is not just for medical doctors. It’s one of the best ways for the doctor of chiropractic to monitor patients’ progress, as well as to maintain complete records that can be used as a defense in third-party audits or malpractice suits.
Unfortunately, says Susan McClelland of McClelland Consulting, one of the nation’s top experts on chiropractic record keeping, “a lot of providers are not documenting the necessary information, especially for Medicare. Medicare has very specific requirements about what you must have in your notes, and those requirements really don’t differ a lot from what today’s standard of care demands.”
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