Improve workflow and make documentation easy with the right software.

In a world where little details matter—in legal and insurance industries, for example—if it wasn't documented, it didn't happen.

"SOAP [subjective, objective, assessment, and plan] notes substantiate the need for care, and, in the event of malpractice, they show, at a bare minimum, that the doctor did everything right," says Paul B. Bindell, DC, president of Life Systems Software in Rockaway, NJ.

According to Bindell, the main reason why doctors lost any cases against the New Jersey state board is because they had poor SOAP notes. Inadequate SOAP notes also can be a frequent cause for payor rejections, which not only result in lost revenue, but also can lead to charges of insurance fraud, Bindell notes. These are steep consequences for a doctor who keeps notes improperly.

However, SOAP notes are a medical tradition, transcending time and disciplines.

"You have to document what is going on," says Michael Silbert, DC, co-president of E-Z Notes Inc, Chicago. "People relying on those notes include future treating physicians, medical examiners, attorneys, and insurance companies."

"The concept of SOAP notes has been around for a very long time, and it is a proven method or style of documentation. The bottom line, though, is accuracy and timeliness," says Ken Schenley, executive vice president at Quick Notes Inc, Fort Lauderdale, Fla.

SOAP notes software can help achieve this accuracy and timeliness. Most programs fit smoothly into workflows, permitting doctors to record their notes as they see patients.

"Notes are completed in real time, so there is no time lapse or worry that they simply will not get done," Schenley says.

The notes are stored in the database, where they can be easily accessed, analyzed, or delivered in reports. The handwriting is always legible, filing is eliminated, and paperwork is drastically reduced. The time saved can be put toward practice-building efforts, managing larger volumes, or boosting revenue.

"Most systems pay for themselves in 2 to 4 months, saving tens of thousands of dollars in transcription fees annually," Schenley says.

Raising the Bottom Line

Life Systems Software created a return-on-investment (ROI) report based on a chiropractic practice with a volume of roughly 150 patients per week.

"The report factors in billed items, actual collections, and the amount of time the staff spends managing paperwork and chasing down payments," Bindell says.

According to the report, implementation of SOAP notes software can, in 1 month, save more than $1,000 in staff salaries, reduce the doctor's time investment by roughly $1,700, and increase collections by nearly $3,700 per month.

"That's about $6,400 a month in increased income or reduced expenses," Bindell says.

Silbert recalls one client who stated that he had made an additional $20,000 in the 6 months following the installation of his SOAP notes software.

E-Z Notes Inc offers a menu of options to users to speed workflow and improve efficiency.

"The system reminded him to bill for things he was already doing but forgetting to charge for," Silbert says, citing neuromuscular education as an example.

Linking the Front and Back Ends

Greater ROI is often realized with more expansive systems that link billing or the electronic medical record (EMR) to the SOAP notes. Some providers offer software suites designed to meet all of a practice's management needs. Other companies specialize in SOAP notes documentation that integrates with other vendors' billing and practice-management software.

E-Z Notes is a specialty vendor that focuses on SOAP notes that respond rapidly to market demands.

"We get recommendations on what to modify from doctors who use the program. About 1,000 docs are using E-Z Notes now," Silbert says. The company releases about 26 updates per year. Newer features include Spanish patient forms and color coding.

However, Silbert believes integration is key to the success of automated documentation systems. He says E-Z Notes integrates with seven or eight other programs.

"Integration minimizes the work that used to be manually done postbilling by administrative staff, so the workflow is much faster," Silbert says. "Chiropractic offices can even request that patients fill out the initial paperwork online, eliminating paperwork and manual data entry, saving patient time in the office that would have been spent completing forms."

Subsequently, it is common to see vendors offering entire suites of software. ChiroPad, Life Systems' SOAP notes documentation system, integrates with the company's ChiroOffice to form ChiroSuite. The broader program manages appointment scheduling, patient billing, insurance processing, phone-call logging, educational and marketing materials, and project management. Quick Notes' EMR and Addison Health Systems' WritePad EMR incorporate SOAP notes software into EMR solutions, offering similar features.

Fitting into the Workflow

Once the software is integrated into practice management, it also should fit smoothly into the chiropractor's routine workflow.

"Doctors in the habit of keeping good SOAP notes on paper just need to exchange the paper form for the computer," Bindell says. "Doctors without good note-taking habits may find it to be easier on the computer."

Users of WritePad can record patient pain on illustrative scales.

Rather than waiting until lunchtime or the end of the day to record notes, doctors can do so while they see patients, making it less likely that they will forget to record anything of significance. Drop-down menus and customization capabilities make notes easy to create.

"It's just mouse clicks and a little bit of typing or handwriting that goes into it," Bindell says.

Most systems work with desktops, laptops, and tablet computers. Tablets can capture handwriting created with a stylus.

"On our tablets, we allow doctors to draw on pain drawings, so they can show the location of pain or acupuncture needles or abrasions and bruises and pop the drawing right into their notes," Silbert says.

Tablets are preferred by many chiropractors because of their configuration flexibility, notebook-like qualities, and screen size (they have also decreased in price, according to Silbert). Smaller screens can sometimes be unwieldy, requiring multiple page scrolls to complete and access information.

"We've found that the smallest screen we can use is a 10-inch monitor," Silbert says.

While many companies have discontinued PDA offerings, portability is after all a key element of HIPAA.

"The key to a good portable system is that it allows you to complete your patient record while still maintaining rapport with your patient," Schenley says.

Tablets are easily transported, but some doctors do not like to carry even those, which may be as light as 3 pounds, and battery use may be limiting. PDAs are therefore an ideal solution for some.

Most systems, like ChiroPad, work with desktops, laptops, and tablet computers.

Quick Notes PDQ is a fully customizable and portable Intelligent touch screen for Palm or Treo/Centro phones. Users tap on the lightweight PDA that features screens with big buttons. The information is then downloaded into the database using Wi-Fi or a cabled connection.

Customizing Programs

Schenley notes that, of course, customers can use their desktop or tablet computers if they prefer. SOAP software, in general, tends to be extremely flexible and customizable.

"No one practices the same way. If we go into 100 different offices, we will find 100 different ways of practicing, and the software needs to be truly customizable to handle that," Bindell says.

ChiroPad offers several levels of customization. The first level is the ability to enter unique information on a screen about a particular patient and visit. The second is the freedom to add information into a note. A third level permits users to create, edit, modify, statistically weigh, and delete the verbiage in the verbiage library.

Many systems offer similar customization features. Quick Notes PDQ buttons can be customized, and text can be added through mini-keyboards or handwriting-recognition programs. E-Z Notes permits modification of the screens and radio buttons as well as unique data entry on each page. WritePad offers optional modules to mirror the screens to a specific practice.

Keeping It Real

Some systems, such as ChiroPad and E-Z Notes, permit doctors to alter the verbiage to generate notes, including randomized text. Others, such as Quick Notes, allow doctors to create the variations themselves. But however it is managed, most SOAP notes software incorporate randomized text generation.

The feature is popular because insurance companies and attorneys don't like identical notes; it can provide the basis for payment denials. Therefore, many SOAP notes systems have programs in place to generate seemingly random text.

"WritePad has a full database of verbiage that it draws from to be able to write out very high-level, randomized, unique sentence structures with variables within those sentences to provide the randomization of the notes," says Greg Winterkamp, CEO and president of Addison Health Systems.

Silbert notes that every sentence in the E-Z Notes library exists between eight and 20 times and can be customized by doctors to match local speech patterns.

"So, if you have 50 or 60 sentences, each of which can be done 25 different ways, then you have billions of phrases," Silbert says. "Doctors can therefore avoid duplicating their notes."

"Let's say a patient came in four times in a row with the same complaints and the same findings and underwent the same treatment. With randomized text, the notes will look different even if they include the same information," Bindell says.

Breaking the Rules

Users also have some control over rules-based features—they can choose to ignore them.

"The doctor needs to be empowered to make the clinical choices that are appropriate for each individual patient based on the doctor's education," Bindell says.

However, helpful reminders are exactly that—helpful. For instance, if a patient comes in with a new complaint, which the doctor treats, the ChiroPad system will remind the doctor to change the diagnosis.

"If you are doing an ultrasound, E-Z Notes will ask for the body part and length of the exam," Silbert says. "WritePad offers alerts and guided workflows, designed to maintain compliance with guidelines, including federal, regional, and industry-specific, such as PART [pain/tenderness, asymmetry/misalignment, range of motion abnormality and tissue/tone/texture abnormality]."

Obeying the Rules

Reports are generally easy to generate, and often they are delivered with the push of a button.

"A really excellent narrative report can be produced in three clicks of a mouse. If a doctor has truly been entering all information into the patient file, when the time for a narrative report arrives, it's ready to mail 30 seconds after pushing 'create,'" Bindell says.

Information also can be used to create business analytic reports, such as tracking patient volume, x-ray exams, or treatment plans.

You could run reports at the end of each business day," suggests Silbert, who admits he does not do this himself. All information is protected according to HIPAA standards, usually through some combination of security passwords and data encryption.

"Some of our clients use a fingerprint device or some other identifier to give patients access," Winterkamp says. "The WriteTouch module lets patients input information online or in office kiosks, which is where users may decide to incorporate security biometrics."

Protection for patients and doctors is one of the advantages of SOAP notes software. Other advantages include time savings, cost savings, and improved patient care. With legible, complete SOAP notes, doctors can see what has occurred before, and what has worked and not worked, in order to make smart decisions going forward. They can then defend those decisions with accurate, clear notes that neither attorneys nor insurance companies can question.

Renee DiIulio is a contributing writer to Chiropractic Products. For more information, contact .