SOAP Notes and Accurate Medical and Billing Coding

SOAP Notes and Accurate Medical and Billing Coding

SOAP Notes and Accurate Medical and Billing Coding

SOAP (Subjective, Objective, Assessment, Plan) notes serve as the foundation for a medical professional’s observations regarding a patient’s condition, and decisions concerning how to go about treating that patient. These are a major aspect of the documentation process of any medical practice. SOAP notes can be highly influential, especially if a medical claim has been rejected or if you are the subject of an audit. Thus, complete SOAP notes, succinct, yet detailed, are important. Here are some SOAP note tips that may serve you well if a medical insurance claim is called into question.

SOAP Note Basics

SOAP notes need to be taken when a doctor or nurse is meeting with a patient. There are many electronic versions of SOAP notes available, making note taking a lot faster and easier. Also, electronic notes can be more accurate than handwritten ones and stored a lot more easily. Finally, these notes should be completed as soon as possible; preferably before the practitioner sees the next patient.

If a patient has more than one complaint, notes may be organized according to each complaint and then appropriate symptoms, data, and observations listed under each problem. This will help keep the information organized, aid in developing your assessment and plan, and help provide the underpinning you need to properly code for insurance purposes.

Coding and SOAP Notes

It’s very important that coding conform to the information in your SOAP notes, as this, along with diagnostic tests, will serve as the foundation for your insurance claim. With ICD-10, coding becomes a more complex process. There are codes related to whether or not the patient has made an initial or return visit for the complaint, the exact area affected by the injury or illness, the method by which an injury occurred, and the possible longevity of the illness or injury.

Thus, the more specific your notes can be in relationship to coding procedures, the better your evidence will be if there are questions concerning your the patient and your medical claim in regards to their situation.

Invaluable Paper Trail

SOAP notes are important documents for many reasons. First, they allow you to track a patient, the development of their symptoms, their progress or regression when being treated, and the outcome of their situation. They offer you the full picture of the evolving status of the patient.

They also provide you with important backup data and information for any type of audit on the part of medical claims payers and any possible medical malpractice lawsuit. Thus, these notes serve as the official record of how you treated a specific patient, and they should be written so that they can provide the information you need if treatment is in any manner called into question.

A Complete Record

SOAP notes are an integral part of a complete patient record. They provide the foundation that you need for treatment, a method for tracking a patient’s illness or injury, and essential backup for those times when you require accurate and detailed information. Coordination of these notes with ICD-10 and ICD-9 codes will enable you to substantiate any treatment that is questioned and any possible audit.

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