Ever heard the phrase, “If it wasn’t written down, then it didn’t happen”? While that might sound extreme in some contexts, it’s the law of the land in the medical field.
Medical documentation is an essential component of any practice; it can exist in a multitude of ways, but one of the most important forms of medical documentation is known as SOAP notes. These writings keep you and your practice out of hot water, result in better patient outcomes, and provide a comprehensive paper trail for the patient’s healthcare journey.
But what are soap notes? How do they relate to medical billing? We’ll dive into all of that in this article; keep reading to learn more!
What Are SOAP Notes?
SOAP notes are a standardized form of healthcare documentation; the letters stand for Subjective Objective Assessment and Plan. Each component of this formula is essential to compiling a well-rounded report of the patient’s current experience and evaluating the best care plan.
Let’s break down each of the letters:
This section starts off your documentation with an understanding of what the patient is experiencing at the moment; this includes their feelings, perspective, and personal views as relevant to the treatment setting. This section provides context for why the patient is visiting your medical practice and empowers the patient to put into their own words what is going on with them.
Depending on the setting of your practice and what type of treatments you offer to your patients, this section might have a few other subheadings to further elaborate on what the patient is experiencing.
For example, you might include the following sections:
- Rate the severity of pain on a scale of 1 to 10 and describe it (dull, cramping, shooting, aching, etc.)
- Note the places of pain on the body
- Explain how the pain started and how it might change during the day with different movements, what makes it worse or what helps reduce the pain, etc.
This initial section is important for illuminating how a patient’s condition is affecting them so that you can determine how best to address their pain points—both literal and metaphorical.
To complement the subjective experience of the patient, SOAP notes follow up with objective, unbiased facts pertaining to their condition.
This information might include:
- Patient’s vital signs
- Imaging results
- Lab data
- Behavioral or physical signs
- Body posture
- Range of motion
It’s important to distinguish between symptoms and signs in this section; symptoms are considered subjective whereas signs are considered objective notes. As with all medical documentation, it’s also crucial to filter out any kind of assumptions or exaggerations; each objective note should be verifiable through evidence.
This step involves bringing together the subjective and objective so that you can determine what might be ailing your patient. You might list a variety of problems or diagnoses that the patient is presenting, ranging from most to least severe or important. This part of your medical documentation is critical because it shows your thought process of going from patient feelings and objective notes to your conclusions.
Now that you’ve evaluated the patient and have drawn up some conclusions or directions to explore, you’ve got to have a plan. This section nicely rounds out this iteration of medical documentation and might include:
- What follow-up appointments are needed
- Referrals to other specialists
- Orders for further testing
- Therapy needed
This part is essential because it provides next steps for the patient to follow and serves as a reliable history for the patient’s wellness journey.
How Do SOAP Notes Relate to Medical Billing?
If you think about it long enough, just about everything pertaining to your medical practice relates to your medical billing process because that’s the foundation of your overall healthcare revenue cycle.
SOAP notes, in particular, are vital to the insurance billing process because healthcare documentation is needed to justify the medical codes you include in your claims. You can’t just submit whatever codes you want to get reimbursed for – thus having SOAP notes and other pertinent medical documentation to justify your codes is helpful.
Medical documentation like SOAP notes ideally follow a logical line of thinking and consider multiple factors within the patient’s wellness journey; this leads to a decrease in patient risk and an increase in patient outcomes. This is, obviously, a win-win for everyone involved!
When used in conjunction with other forms of healthcare documentation, SOAP notes are a tremendous resource for you, your practice, and your patients.
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