| Doctors and therapists must produce clinical | | | | medications ordered, treatments performed (e.g., |
| documentation in ever increasing volumes and | | | | minor surgery procedure), patient referrals |
| detail to ensure best healthcare, get medical | | | | (sending patient to a specialist), patient disposition |
| claims paid in full and on time, and protect the | | | | (e.g., home care, bed rest, short-term, long-term |
| practice from post-payment audits and unfair | | | | disability, days excused from work, admission to |
| litigation. | | | | hospital), patient directions and follow-up directions |
| But visit documentation speed conflicts with | | | | for the patient. |
| documentation accuracy and thoroughness. For | | | | Next, each one of the four key SOAP stages |
| insurance companies, patient visit documentation | | | | consists of templates reflecting multiple possibilities |
| must be precise and comprehensive. If the quality | | | | for each stage. Templates, organized according to |
| of documentation is high, the medical billing appeals | | | | SOAP order, ensure comprehensive coverage and |
| on unpaid claims are paid faster and at a higher | | | | allow the doctor simply check multiple selection |
| rate. Otherwise, appeals are denied and the | | | | boxes on the screen driven by a computer |
| practice becomes vulnerable to post-payment | | | | program. |
| audits, refunds, and penalties. | | | | Templates have attracted two-fold criticism both |
| Insurance companies do not care how long does it | | | | from the provider and the payer sides. The |
| take to produce good documentation. But for | | | | providers dislike the lack of built-in intelligence to |
| provider, slow documentation impedes practice | | | | reflect individual doctor's preferences to treat |
| profitability and wastes valuable time. The doctor | | | | patients. The payers often suspect |
| must be done with visit documentation by the | | | | template-generated notes of low quality and poor |
| time the patient leaves the office. | | | | reflection of true patient state and treatment |
| To ensure comprehensive note coverage, | | | | progress because template susceptibility to |
| healthcare industry adopted a two-pronged | | | | mechanical clicking and difficulty of interpretation. |
| structured approach. First, the doctor uses SOAP | | | | The challenge is to combine the advantages of |
| notes format, which reflects four key stages of | | | | template and verbose formats without their |
| patient care, starting from Subjective | | | | shortcomings to describe precise patient condition, |
| observations, to Objective symptoms, to | | | | ensure productive medical billing, prepare for |
| diagnostic Assessment, and culminating with | | | | regulatory scrutiny, and improve practice |
| treatment Plan: | | | | productivity. To overcome the perception of |
| | | | mechanically generated notes while saving the |
| 1. SUBJECTIVE: The initial portion of the SOAP | | | | doctor the time to type, some vendors have |
| note format consists of subjective observations. | | | | created specialized products that use randomized |
| These are symptoms typically expressed verbally | | | | wording for each template. Such automatically |
| by the patient. They include the patient's | | | | generated notes include sentence structures, |
| descriptions of pain or discomfort, the presence | | | | which closely resemble natural speech patterns. |
| of nausea or dizziness or other descriptions of | | | | Flexibility and integration must be key design |
| dysfunction. | | | | features of SOAP notes. In the opening section, |
| 2. OBJECTIVE: The next part of the format | | | | for example, you create new patient files that |
| include symptoms actually be measured, seen, | | | | grow organically with each visit or treatment. |
| heard, touched, felt, or smelled. Included in | | | | Built-in intelligence allows you to customize a |
| objective observations are vital signs such as | | | | document to your own preferences and observe |
| temperature, pulse, respiration, skin color, swelling | | | | the entire patient progress history in a single |
| and the results of diagnostic tests. | | | | screen. Native system integration with medical |
| 3. ASSESSMENT: Assessment is the diagnosis of | | | | billing systems, enable automated claim generation, |
| the patient's condition based on Subjective | | | | validation, and submission to payers for payment. |
| observations and Objective symptoms. In some | | | | SOAP notes must not merely emulate the paper |
| cases the diagnosis may be a simple | | | | folder that every doctor has for every patient. |
| determination while in other cases it may include | | | | They must use computer technology to help |
| multiple diagnosis possibilities. | | | | automate routine tasks and create a faster, |
| 4. PLAN: The last part of the SOAP note is the | | | | easier, and error free process to increase practice |
| treatment plan, which may include laboratory and | | | | profitability and reduce its audit risks. |
| or radiological tests ordered for the patient, | | | | |