SOAP Notes Can Clean up Your Records

The O&P profession we have known to date is having its proverbial reset button pushed. How we have done things in the past will no longer serve to keep us viable in the market, and many things are quite simply out of our control during this time of change. However, focusing on what we can control will help us have a stronger hold on our businesses and practices when the dust settles. One area we have 100 percent control over is documentation.

Providing proper and clear documentation to third-party payers helps to ensure proper payment of claims and protects your business in the case of audits. Though from a national perspective, based on evidence from Medicare studies, documentation is the one area in which the O&P profession has shown to be lacking and even deficient in our practices. In all of healthcare, there is a push by payers for better and more thorough documentation. We in the O&P profession are in the unique situation not only of providing a service, but also delivering a product, heightening our need to effectively explain and demonstrate our knowledge. We are a member of our patient's medical team and the entire medical team must be on the same page and paint the same picture about that patient—which also substantiates the push for corroborated notes. One of the most widely used and universally accepted forms of chart note writing in the medical community is the SOAP note method.

SOAP is an acronym for "subjective, objective, assessment, and plan." It is a structured documentation style that provides a format with which most medical professionals are familiar and are likely to use. Much current research shows that physicians who use a structured text format for documentation include information about the patient that is more specific than when they use free text writing, dictation, or a prompt-based system. The following breakdown outlines the type of information that should be included in each section.

• Subjective: This is the information you gather from the patient—you are collecting your patient's story. Why did he or she come in? What hurts? What are his or her goals? Have the patient describe his or her lifestyle and the ways he or she will reach those goals. It is important to get the patient talking and avoid close-ended questions that permit only yes or no answers.
• Objective: In this section, the practitioner explains what he or she sees about the patient upon beginning the appointment. Did the patient come in wearing the brace or prosthesis? Was he or she accompanied by someone? What is his or her cognitive state? Is the patient saying he or she wears the brace or prosthesis "all the time" but the device shows little wear and tear? Any obvious weight gain or weight loss? Be sure to avoid using judgment-based statements that may be from your own frame of reference rather than from dispassionate eyes. This is also the section where you want to make sure you are corroborating the physician notes and painting the same picture to create as much synchronicity between the charts as possible. And finally, do the patient's subjective statements concur with what you are seeing? A statement about whether or not there is a link between the actions and words from the patient and what you are seeing should be included.
• Assessment: In this section, the practitioner's clinical knowledge is given the front seat. State what is going on with the patient clinically. Explain what needs to be done to address the reason for the patient's visit and why.
• Plan: Describe what you did to alleviate the problems diagnosed in the assessment section. What actions did you take? Include a clear and concise plan for follow-up, including the specific timeframe over which it will happen (two weeks, three months, etc.). In the case of "follow-up as needed," be sure to state a specific and scheduled follow-up based on your office's standard protocol.

SOAP Up Your Electronic Records

The medical community as a whole is moving toward an electronically based record: An electronic health record (EHR) refers to a patient record that is available to a broad network of practitioners and facilities, and an electronic medical record (EMR) contains information from one provider or practice involved in a patient's care. There are O&P-focused EHR and EMR software providers that do a great job of providing us with the technology to run our businesses effectively and getting us up-to-date with medical documentation standards using quick and easy program prompts. Some argue, however, that prompt-based systems have a tendency to create generic patient notes and that if the patients' names were removed from the charts, many of the chart notes are similar to the point of being indistinguishable from patient to patient. If you use this type of system, make sure to take full advantage of text boxes to create differentiation between your patients. Using the SOAP format in these areas will help you to become more specific about your patient interactions and paint a more thorough and corroborated picture.

Quality Over Quantity

There is one last point to remember writing when patient chart notes: The quality of the content, not the quantity, matters.

Payers have to be satisfied with the content. The payer source is your customer, and the patient is your client—the one who benefits from your work. This paradigm shift must be accepted with haste. If we do not address the quality of our documentation from a medical necessity perspective, our customers will deny payment and our practices will be in jeopardy. The days of three-sentence delivery notes are over. Payers look at the patient's historical medical chart and make payment based on the objective medical necessity for the patient, not on inference of what the patient "could do" The latest school of thought is that the patient has to take responsibility for his or her own care, and it is the job of the payer to provide the patient with the same functionality he or she had prior to the incident—nothing more, nothing less. This is precisely why corroboration with the physician's notes is integral. Payers are looking at the entire chart and deciding whether or not the physician and the O&P practitioner are painting the same picture about our patient, and if there is a discrepancy between the charts, the physicians notes will be given precedence.

Digging our heels in and decrying the unfairness of changes in documentation is no longer an option. Our profession has gone through several major changes over the years as technology has advanced. This emphasis on documentation, in essence, is another change that provides us with an opportunity to adapt and to grow our relationship with other healthcare team members as we adopt a common documentation language. Our practices will change. How we operate on a daily basis will change. How we service our patients will change. Allow this change to invigorate your offices and practices rather than have it become something that is vehemently protested.

Develop a plan to incorporate the SOAP documentation format while focusing on the medical necessity of why you are proposing the course of treatment. Learn from any setbacks or mistakes you encounter, but stick with it and keep moving forward with your efforts. O&P practices and practitioners that are willing to make these changes in their businesses will be able to survive the storm and come out thriving.

Leslie Roberts, MSS, CP is the U.S. manager for Nabtesco Proteor - USA, Muskego, Wisconsin. She graduated from the Northwestern University Prosthetic-Orthotic Center, Chicago, Illinois, in 2005 and has worked as a prosthetist in both private and corporate-based practices.