30 May SOAP Notes and Efficient Medical Coding and Billing
Dr. Lawrence Weed developed SOAP notes in the 1960s at the University of Vermont. SOAP is an acronym for Subjective, Objective, Assessment and Plan, and these categories relate to the manner in which a doctor, nurse, or other medical professionals record their meetings, assessments, and treatments of patients. SOAP notes are a standard part of any healthcare visit, service, or procedure and have become a part of best practices.
These notes can go a long way to justifying medical charges, identifying medical codes that should be used, and creating a history of medical treatment and the efficacy of such. Thus, SOAP notes should not be seen as something that should be done because it’s expected, but as a tool that can facilitate effective medical coding and billing.
Telling the Story
In essence, SOAP notes are what a physician uses to record information concerning a patient and their complaint. The notes contain both subjective and objective observations from which the practitioner makes their assessment and then offers the next steps to be taken in diagnosing, treating, or advising the patient. It’s a simple enough idea, yet these basic notes are important in many ways.
First, they are the primary manner that a healthcare worker has in documenting a patient’s condition. Thus, SOAP notes are important in terms of treatment. At the same time, they are the main way in which a healthcare professional justifies tests, procedures, prescriptions, and more. That makes SOAP notes very important when it comes to coding, billing, and filing a claim. They are especially vital if you’re audited, as they offer supportive evidence for patient services that have been provided.
Keeping Complete Notes
It’s essential that one keep complete notes. That means covering all four categories adequately. One or two sentences usually won’t do. Yet, SOAP notes don’t need to be excessive. These notes need to be consistent and comprehensive. For patients that are seen multiple times, it’s important that you track changes, comment on progressive or lack of such, and put the patient’s condition in perspective. Consider these notes in relationship to the treatment and services you’re providing.
Computer Generated Notes
In recent years, handwritten SOAP notes have become passé. This has occurred for numerous reasons with the ultimate one being that computer generated SOAP notes are extremely efficient to record and access. Everything you need to properly document a patient’s condition, your diagnosis, and their treatment may be recorded on a portable tablet.
Plus, for patients with chronic conditions that you see over an extended period of time, you can copy and utilize certain notes on later reports. This can save time, while allowing you to also document any changes in their condition you’ve observed. Notes are easily stored and can be shared quickly when needed. If required for audits or appeals, they can be accessed and read effortlessly.
Supporting Medical Coding and Billing
SOAP notes were primarily developed to track patient symptoms, conditions, diagnosis, and treatment. In doing so, they also provide important support for those performing your medical coding and billing. It’s important to have a system in place that ensures your SOAP notes are completed in a thorough and timely fashion. Doing so will go a long way to supporting the physical and mental health of your patients and the fiscal health of your practice.
MPMR offers nationwide medical billing and coding services to help your practice grow and thrive. Not only does MPMR have top certified coders, but also operations specialist to evaluate and improve your efficiencies. Call us today!