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.
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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“SOAP notes have been in use in chiropractic now for about the last 20 years, but we still have a number of practitioners who don’t use them properly,” says Tony Hamm, DC, ACA vice president, who practices in Goldsboro, N.C. “People often say that it takes too much time and takes away from seeing patients, and that they don’t get paid that much to do documentation.”
But in reality, says Dr. Hamm, you are getting paid to maintain progress notes. “When a CPT code, like an exam procedure, is billed, there is a postservice component that is part of the value of the code, and that includes documentation,” he says. “It’s built into the relative value (RV) of the service itself. If that weren’t built in, we would actually get paid less for that service. Most people probably don’t realize that.”
So if you’ve been skimping on your SOAP notes, it’s time to scrub up. SOAP is a simple mnemonic, which stands for Subjective, Objective, Assessment and Plan.