Physicians and therapists must produce clinical documentation in increasing volumes and details to ensure the best medical care, get medical claims paid in full and on time, and protect the practice from post-payment audits and unfair litigation.
But the speed of the visit documentation conflicts with the precision and thoroughness of the documentation. For insurance companies, documentation of the patient’s visit must be accurate and complete. If the quality of documentation is high, medical billing appeals on unpaid claims are paid faster and at a higher rate. Otherwise, appeals are rejected and the practice becomes vulnerable to post-payment audits, refunds, and penalties.
Insurance companies don’t care how long it takes to produce good documentation. But for the vendor, slow documentation impedes the profitability of the practice and wastes valuable time. The physician must have completed the documentation of the visit before the patient leaves the office.
To ensure full coverage of the notes, the healthcare industry took a structured two-pronged approach. First, the clinician uses the SOAP note format, which reflects four key stages of patient care, starting from subjective observations to objective symptoms, diagnostic evaluation, and culminating with the treatment plan:
- SUBJECTIVE: The initial part of the SOAP note format consists of subjective observations. These are symptoms that the patient usually expresses verbally. They include descriptions of the patient’s pain or discomfort, the presence of nausea or dizziness, or other descriptions of dysfunction.
- OBJECTIVE: The next part of the format includes having symptoms actually measure, see, hear, touch, feel, or smell. Objective observations include vital signs such as temperature, pulse, respiration, skin color, swelling, and results of diagnostic tests.
- EVALUATION: Evaluation is the diagnosis of the patient’s condition based on subjective observations and objective symptoms. In some cases, the diagnosis may be a simple determination, while in other cases it may include multiple diagnostic possibilities.
- PLAN: The last part of the SOAP note is the treatment plan, which may include ordered laboratory and / or radiological tests for the patient, medications ordered, treatments performed (e.g., Minor surgery procedure), patient referrals (referral to a specialist), disposition (e.g., home care, bed rest, short- or long-term disability, days absent from work, admission to hospital), patient instructions, and patient follow-up instructions .
Each of the four key stages of SOAP then consists of templates that reflect multiple possibilities for each stage. The templates, arranged in SOAP order, ensure complete coverage and allow the clinician to simply tick multiple checkboxes on the screen driven by a computer program.
The templates have drawn double criticism from both the provider and those who pay. Providers dislike the lack of built-in intelligence to reflect individual physician preferences for treating patients. Payers often suspect that template-generated notes are of poor quality and a poor reflection of the patient’s actual condition and treatment progress due to the templates’ susceptibility to mechanical clicks and difficulty of interpretation.
The challenge is to combine the advantages of the template and detailed formats without their shortcomings to describe the precise condition of the patient, ensure productive medical billing, prepare for regulatory scrutiny, and improve practice productivity. To overcome the perception of mechanically generated notes while saving the doctor time to write, some vendors have created specialized products that use random wording for each template. These automatically generated notes include sentence structures, which closely resemble natural speech patterns.
Flexibility and integration should be key design features of SOAP notes. In the opening section, for example, create new patient files that grow organically with each visit or treatment. Built-in intelligence allows you to customize a document to your preferences and view all of the patient’s progress history on a single screen. The integration of the native system with the medical billing systems, allows the generation, validation and sending of automated claims to payers for payment.
SOAP notes should not simply emulate the paper folder that every doctor has for every patient. They should use computer technology to help automate routine tasks and create a faster, easier, and error-free process to increase the profitability of the practice and reduce audit risks.