Medical documentation is an essential part of your medical practice – it’s how you provide a historical record of your patients’ progress, support your insurance claims, and break down silos between healthcare providers. Plus, better medical documentation results in better patient outcomes and lower patient risk.
However, medical documentation, like SOAP notes, can be ineffective and incredibly time-consuming if you’re not careful to avoid some common mistakes. In this article, we’ll go over the basics of SOAP notes, why your medical documentation is vital to the success of your practice and point out some of the common mistakes in SOAP notes that you should avoid.
Keep reading to learn more!
- What Are SOAP Notes?
- The Importance of Medical Documentation and SOAP Notes
- 3 Common Mistakes to Avoid in Your SOAP Notes
What Are SOAP Notes?
Originally developed for traditional medicine settings, like hospitals, SOAP notes are a core component of almost every corner in the healthcare industry. These notes – which include sections for Subjective, Objective, Assessment, and Plan – are great for gathering a comprehensive report of a client’s wellness journey.
Let’s review what each section is meant to include:
In this initial section, you would want to include details about how the patient subjectively feels and what their internal experience is like in their own words. For example, does your client feel achy and sore when they’ve been sitting for too long? Does their brain feel fuzzy after taking a new medication? Documenting their subjective experience is critical for your SOAP notes and establishes a rapport between patient and provider.
This section is where you’d note details relating to the patient’s condition. For example, their blood pressure and other vitals, if they have limited range of motion or if they’ve developed a rash. These pieces of information must be able to be supported by objective statements and evidence – hence the term objective.
For this third part of your SOAP notes, you would provide your assessment of the patient. This includes elaborating on what type(s) of condition your patient might have, your reasons why, and provide updates on how the treatment plan is progressing over the course of your following sessions.
Finally, your SOAP notes conclude with a section discussing the plan of action you have for your patient. What are their immediate next steps? What should they monitor in the meantime? When will they return to your practice for another session of treatment? These details are important to include in medical documentation because it ensures all communication is aligned and that the patient knows what to anticipate in the future.
The Importance of Medical Documentation and SOAP Notes
Now that we’ve covered the basics of SOAP notes, let’s discuss what medical documentation as a whole means to your medical practice.
The phrase “If it wasn’t documented, it didn’t happen” certainly applies here – medical documentation is critical to capturing real-time information that relates to or impacts your patients. Gathering a comprehensive analysis of your patient’s condition in the moment and then over the course of time and subsequent visits results in a deeper insight that reveals patterns or other clues into the patient’s condition and progress.
Plus, in acquiring this well-rounded information, your patient outcomes will increase as patient risk decreases. Evaluating multiple perspectives and compiling various details means you’ll be less likely to overlook details while further building rapport with your patient. Better patient engagement is always a win for your medical practice!
One more thing: medical documentation is essential for your overall healthcare revenue cycle! Having detailed records is beneficial because these records and notes support your medical coding and billing claims. This means you’ll have minimal issues getting reimbursed because you weren’t “winging” your coding – you were appropriately coding your claims.
3 Common Mistakes to Avoid in Your SOAP Notes
While there aren’t any shortcuts to good quality SOAP notes, there are some common pitfalls you can watch out for, like these 3 common mistakes:
Mistake #1: Including statements without supporting evidence
Your SOAP notes should have sources and evidence to support them. This means that they should be unbiased and be an accurate reflection of what occurred during your session with the patient. For example, if a patient seems happy, then you’d want to note what evidence you have for that statement, e.g., the patient was joking around and smiling.
Mistake #2: Using vague language when you could include more details
While you shouldn’t spend hours writing your SOAP notes, it is important to include details and specifics in your report. A common mistake is making general statements or being too brief in your writing, which isn’t properly leveraging the SOAP notes format.
For example, glossing over important aspects of your patient’s condition by saying “Patient is experiencing lower back pain” – for more details, you would include what kind of pain (sharp, dull, achy, etc.), how long the patient has been experiencing this, if movement helps or hurts, and more. These details paint a more vibrant picture of your patient’s condition.
Mistake #3: Saying the same thing in each of the SOAP note sections
Another common mistake people make is regurgitating the same information in each section of SOAP notes. This ultimately defeats the purpose of SOAP notes, which is to comprehensively interpret and analyze a patient’s condition. If you’re just repeating yourself, then you aren’t fully documenting multiple perspectives or details that can help illustrate your patient’s condition or symptoms.
For example, don’t include how the patient is feeling in your Assessment notes but do include how they describe their pain in the Subjective section! It might help you or new staff members to keep a list of what each section is meant to cover handy until you know how to fill in each spot appropriately.
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