EHR Guru

Archive for February, 2012...

Filed under Soap Note Lesson Series

It’s important to understand and properly document a patient encounter. The bottom line is that you must show medical necessity. That is the Medicare way and all other carriers follow suit.

Another important point I want to make is that regardless of your type of practice (cash, PI, family, sports, etc) your documentation should be the same as every other practice. Standardizing notes is a step in the right direction for fewer denied claims and improving the public Chiropractic image.

In this lesson I want to cover the Subjective portion of your soap note. The Subjective is one of the easier parts of documenting. To simplify: Why is the patient coming to see you? Now don’t get me wrong, writing just LBP or NP isn’t going to cut it. You need to express in the patient’s own words why they are complaining of. “It really hurts when I twist my arm all the way behind my back”, to this the doctor says: “well let’s not do that anymore” (haha). Only teasing, but the subjective still consists of what has been taught for years.

Let’s start with an example of a proper documented Subjective complaint:

Alex came in today complaining of neck pain that started on 7/1/2010. He said, “I woke up with a stiff neck last Sunday”. The symptoms are bilateral with moderate pain occurring frequently (51-75% of the day). He describes the pain as sharp and stabbing with radiating pain to his right shoulder. Ice and heat do improve the pain although the pain has remained about the same since onset and pain is rated at a 5 on a 1-10 scale (0 being no pain and 10 being excruciating). Pain is aggravated by turning his head from side to side and bending over.

In breaking this down we are covering all of the basics. You may have learned the O.P.Q.R.S.T. acronym when you were in school or at a seminar. This is a great model to stick with and actually documents above and beyond the minimum requirements.

O.P.Q.R.S.T.

  • Onset- When did the pain begin?
  • Provokes- What makes the main worse?
  • Quality- Describe in the patient’s words what kind of pain they have.
  • Radiates- Does the pain radiate to a body part?
  • Severity- What kind of pain level are we talking about?
  • Time- When did the pain start and how long has patient had condition?

Using this model is very strong. Medical documentation related to proper E&M coding requires 4 components of the HPI (History of Present Illness) be documented during the initial exam. As you can see, the above model covers 6 of them.

The same process needs to be done for all major complaints. If you prefer to treat them all at once, your initial exam and intake process will be lengthy. Another idea you may consider is to treat only 1 major condition at a time and when one complaint is at a satisfactory level for the patient, you then address the next item on their list. This reduces the documentation burden per visit and allows you and the patient to focus on one item at a time.

The history of this condition should be taken by the doctor directly. Staff does not have the proper training to recognize a risk factor so a doctor should do this portion of intake with the patient.  This is something you should keep in mind.

 

Comments (0) Posted by Alex Niswander on Monday, February 27th, 2012

Filed under Soap Note Lesson Series

What’s in a soap note?

It’s important as a practicing doctor to keep up with current documentation guidelines for Medicare and major insurance carriers.

All of us (and by us I do mean you) should already know the basic of S.O.A.P. and what needs to be documented, ( i.e. what hurts, what do you think, what are you going to do to fix it and when to come back). You also probably have a basic understanding of  documentation, however if we put 5 Chiropractors in a room and ask more specifically about what needs to be in the Subjective part of the note , we would likely come away with more than 5 answers.

Let me ask you a question. Have you been to a weekend seminar and come back thinking you have something to change about how you do patient notes?? Of course you have! Almost every week I get a call from a doctor that goes something like this: “Hi Alex, this weekend I was at Dr. Joe’s seminar – who is an expert in coding and he said that we should be doing XYZ in our notes…..”

The first question I ask if how does he or she REALLY know what should or shouldn’t be in your notes? The answer is no one is truly a “documentation expert” except for maybe a 20 year Medicare employee who has seen it all… You have to take responsibility for doing your homework and finding supporting documentation to use as proof. Remember if you lose a note audit, ignorance will not be a valid excuse and they could still come down pretty hard on you.

My philosophy on patient notes is to be uniform, with a little more detail than the other healthcare specialties. Why should Chiropractic notes be different? Why should we give patients a bubble sheet like they are taking an ACT test for their history? How could we do charts differently and expect fair treatment with insurance companies and Medicare? The honest answer is we can’t and if we don’t provide the same or similar documentation and billing, how could we ever expect to be treated the same??

There is quite a bit of confusion and misinformation on what specifically needs to be in your soap note for patient encounters. Proper documentation is needed for proper caring for your patients, protecting yourself from audits and malpractice law suits. While the later is rare, it still happens.

Ask your malpractice insurance rep if documentation ever plays a major role in their cases.

Our first part of this series: What’s in a soap note – Part 1 – History and Complaint will be sent in our newsletter next week. It is a 6 Part Series.

Please stay tuned!

Thank you,

 

Alex Niswander

Comments (0) Posted by Alex Niswander on Monday, February 20th, 2012