Doctors and therapists must produce clinical documentation in ever increasing volumes and detail to ensure best healthcare, get medical claims paid in full and on time, and protect the practice from post-payment audits and unfair litigation.
But visit documentation speed conflicts with documentation accuracy and thoroughness. For insurance companies, patient visit documentation must be precise and comprehensive. If the quality of documentation is high, the medical billing appeals on unpaid claims are paid faster and at a higher rate. Otherwise, appeals are denied and the practice becomes vulnerable to post-payment audits, refunds, and penalties.
Insurance companies do not care how long does it take to produce good documentation. But for provider, slow documentation impedes practice profitability and wastes valuable time. The doctor must be done with visit documentation by the time the patient leaves the office.
To ensure comprehensive note coverage, healthcare industry adopted a two-pronged structured approach. First, the doctor uses SOAP notes format, which reflects four key stages of patient care, starting from Subjective observations, to Objective symptoms, to diagnostic Assessment, and culminating with treatment Plan:
- SUBJECTIVE: The initial portion of the SOAP note format consists of subjective observations. These are symptoms typically expressed verbally by the patient. They include the patient’s descriptions of pain or discomfort, the presence of nausea or dizziness or other descriptions of dysfunction.
- OBJECTIVE: The next part of the format include symptoms actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests.
- ASSESSMENT: Assessment 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 diagnosis possibilities.
- PLAN: The last part of the SOAP note is the treatment plan, which may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions and follow-up directions for the patient.
Next, each one of the four key SOAP stages consists of templates reflecting multiple possibilities for each stage. Templates, organized according to SOAP order, ensure comprehensive coverage and allow the doctor simply check multiple selection boxes on the screen driven by a computer program.
Templates have attracted two-fold criticism both from the provider and the payer sides. The providers dislike the lack of built-in intelligence to reflect individual doctor’s preferences to treat patients. The payers often suspect template-generated notes of low quality and poor reflection of true patient state and treatment progress because template susceptibility to mechanical clicking and difficulty of interpretation.
The challenge is to combine the advantages of template and verbose formats without their shortcomings to describe precise patient condition, ensure productive medical billing, prepare for regulatory scrutiny, and improve practice productivity. To overcome the perception of mechanically generated notes while saving the doctor the time to type, some vendors have created specialized products that use randomized wording for each template. Such automatically generated notes include sentence structures, which closely resemble natural speech patterns.
Flexibility and integration must be key design features of SOAP notes. In the opening section, for example, you create new patient files that grow organically with each visit or treatment. Built-in intelligence allows you to customize a document to your own preferences and observe the entire patient progress history in a single screen. Native system integration with medical billing systems, enable automated claim generation, validation, and submission to payers for payment.
SOAP notes must not merely emulate the paper folder that every doctor has for every patient. They must use computer technology to help automate routine tasks and create a faster, easier, and error free process to increase practice profitability and reduce its audit risks.