Billing and Coding: Accurate SOAP Notes Are Important

Billing and Coding: Accurate SOAP Notes Are Important

In the medical billing and coding field one of the most important parts of any claim are the SOAP notes that are recorded by healthcare personnel. Along with being a major part of a patient’s medical record and history, these notes help to justify procedures, services, prescriptions, and medical devices.

Top medical billing and coding companies such as MPMR are able to assist with record keeping advice so reimbursement is accurate.

The Essence of SOAP Notes

canstockphoto9049280The acronym SOAP stands for subjective, objective, assessment, and plan. It is under these headings that doctors record what they observe when examining a patient, analyzing their situation, and how they will proceed to treat the patient. These assess a patient’s progress or setbacks from their last visit and help to support further treatment and medical claims.

Complete SOAP Notes are Essential

In completing the subjective section of the SOAP notes, the practitioner records information concerning how the patient is feeling. Included is information concerning symptoms, and it would also include, in subsequent visits, the patient’s observations concerning any changes in his/her symptoms. This section may be filled out in part by an attending nurse.

The objective section of the SOAP notes is devoted to physician or healthcare worker observations concerning the patient’s medical state. Vital signs are recorded in this section, including a patient’s temperature, blood pressure, heart rate, and respiratory rate. Also included is any information related to discoveries made during the examination. If there are blood tests, imaging, or other tests performed, those results would be recorded in the objective section.

Using information from these two sections, the physician may then fill out the assessment and the plan for treatment either immediately after the visit, or, if tests are involved, as soon as they receive the results.

Why Inaccuracy Occurs

canstockphoto5269409Medical practitioners who provide inaccurate or incomplete SOAP notes run a great risk of not only having a claim rejected, but of dealing with an insurance audit where previous claims are reexamined. Under this process, doctors can be made to return payments already made by insurers, resulting in large monetary losses. Thus, inaccuracies in SOAP notes should always be avoided.

The reason why SOAP notes are incomplete or not accurate has to do with physicians not taking the time to properly fill them out in a timely manner. With the advent of computerized notes, which have helped to facilitate the recording process, there’s no reason for a physician to wait to complete the first section of their notes and much of the second.

Often much of this work can be done during the examination process, with the remaining notes in the subjective section completed immediately after meeting with the patient. The entire process usually takes a minute or two, and finishing it up before moving onto the next patient can save time in many ways.

Although part of the objective section and the other two areas may need to be finished after tests are performed, if no tests are ordered, these sections may also be completed right after the examination, or, if more information is needed, they may be partially filled in and finished later on. If this is the case, practitioners need to make sure that they have enough information recorded to accurately complete the notes as soon as all test results come back.

Waiting to finish notes later on or taking sketchy notes can lead to:

• Inaccurate recording of information
• Lost data
• Inaccurate assessment and planning
• Submission of incomplete reports

Plus, if reports are incomplete, it takes additional time to find and review those reports before completing them.

We’ll Make Sure You’re on Target

The medical billing and coding professionals at Medical Practice Management Resources, Inc., are focused on making sure that every aspect of your medical claim is complete and accurate. This is one of the ways that we work to expedite your claims and facilitate timely payments. Ensuring your SOAP notes are accurate and complete will help ensure this process proceeds without delay.

Call the best medical billing firm today, MPMR!

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