The insurance companies are out to get us. Their approach is to attack by auditing our files, finding discrepancies between our SOAP notes and billing, and then demanding refunds and filing charges of fraud. Our only defense is to make our SOAP notes as rock solid as possible. Remember: If it is not in your notes, the insurance auditor says it never happened.

If you are still handwriting your notes, this means taking 15 to 20 minutes per note to provide all the details necessary to satisfy the insurance carriers. The time to produce great SOAP notes and patient documentation can be reduced to seconds, if you use the right computer software program to produce your records.

In this article, the first in a three-part series, we will focus on the basic SOAP categories. Future articles will cover the other areas of documentation, including examinations, history, and narrative production.

Make the Right Selection

Selecting the right documentation program for your office is challenging, but not that difficult if you look for the functions that make it easy. Some of the general features to look for include a system that is paperless, flexible, customizable, and easily personalized for each patient. The speed of entry is important, and with some programs, notes for recurring patients can be created in just a few seconds.

Within each section, it is critical to have many specific functions. Flexibility means you use only the parts of the system your practice needs, which can then be easily moved from one part of the system to another.

Subjective Complaint

Subjective Com­plaint covers a lot of territory. There is the main complaint, the related complaints (what other symptoms are spreading out from the main complaint), what factors make it better or worse, and the need to enter unique comments for the current visit. In the Subjective Complaint screen it is essential that a lot of information can be entered with just a click of the mouse or the tap of a stylus. If it is more involved and takes longer than a click, then it is wasting time. The only exception is entering any unique comments that are needed for that visit.

A typical Subjective Complaint screen includes an area to enter the specific comments made by the patient. On this screen, the comments are entered in the upper right corner, and the system retains a record of those statements in the prior tab, allowing you to review them whenever you want. The patient's complaints are listed in the center of the screen, the body view allows you to rapidly identify which areas of the body are included in the complaint, and you have the ability to be as specific in detail as you desire. As part of the subjective complaint, note the tab for "worse/better," which gives you the option to note what things aggravate this complaint and what things relieve it. The DDX tab is a reminder area of other potentially serious issues that the patient may have when he/she has this complaint.

Figure 1. A typical Subjective Complaint screen includes an area to enter the specific comments made by the patient.	Figure 2. The Objective Findings screen allows for rapid entry with a mouse or stylus.

Objective Findings

The Objective Findings screen allows for rapid entry, whether you use a mouse or a stylus. On this screen, the findings of pain, swelling, temperature, hypertonicity or hypotonicity, subluxations, fixations, adjusting technique used, and response to adjustments can all be entered quickly and easily. From one visit to the next, the system "remembers" what was done. In other words, on each visit it is very easy to see what was done on the last visit.

Entering an Assessment and Diagnosis is also done rapidly. On the Assessment screen there are checklists for preexisting conditions and for those factors that have affected the patient's response to treatment. Note that these lists are user modifiable so you can effortlessly edit or add to them. And if there is something so unique that the program cannot automate it, there is a Typewritten Assessment area to add in a unique assessment.

Figure 3. Assessment and Diagnosis is done rapidly with modifiable checklists and a typewritten assessment area.	Figure 4. The Diagnosis screen makes it easy to select the appropriate pattern and ICD items for the patient.

Diagnosis

The Diagnosis screen is a breeze to use. Once you create your own diagnosis patterns, it is a simple step to select the appropriate pattern and select the ICD items that are needed for this patient. Additional options in the diagnosis screen are a visit counter that will pop up a message when the current diagnosis has expired, a button to print a diagnosis history, and an area to enter a narrative diagnosis for those special situations where the standard ICD diagnosis is inadequate. In the fully integrated paperless systems, as soon as you save the diagnosis, it is in the billing end of the software for insurance claims.

The Plan Area

The last section of the SOAP system is the Plan Area. On this screen you record the services you have provided to the patient, the visit status or when the next appointment should be scheduled, and any message that needs to go to the front desk. A major feature in the complete paperless system is that this screen will generate the charges for today's visit, the visit status, and the digital travel card message at your front desk, eliminating paper travel cards and fee slips. This also acts as insurance against audits since your documentation and billing will always match.

Figure 5. The Plan Area allows you to record the services you have provided to the patient.	Figure 6. The system generates a dictation-quality SOAP note once all information is entered.

A SOAP Note Is Created

Once all the SOAP information has been entered, the system generates a dictation-quality SOAP note. The computer converts the mouse clicks or stylus taps into a patient record that can easily be read. Before saving the note, it is important to recognize that even at this point it is possible to edit it, so that you will be sure that your records accurately reflect what you said and did with the patient.

This full English note is what is saved as part of the patient's electronic record. Although you can make these notes as robust or skimpy as you want, keep in mind that the greater the detail, the less likely an insurance auditor will find a problem. Whenever there is a request for patient notes, they are produced at the touch of a button.

From one visit to the next, you only need to change that which has changed since the last visit. After the first visit, on subsequent visits, there are fewer clicks or taps, and the note still includes all the information that is important and is produced in just a few seconds.

Paul B. Bindell, DC, is president of Life Systems Software and is a 1975 graduate of Palmer College of Chiropractic. He has practiced in Rockaway, NJ, since 1976. He has lectured on chiropractic in Brazil and Israel. Contact him at , or at (800) 543-3001.