A uto accidents, falls and other personal injuries happen regularly. In order for your patient to benefit from your care, and for you to get paid,you must have substantial documentation in your SOAP notes that justifies the care you provided. Due to insurance rules and policies, State Board regulations, and Federal legislation, the depth of detail in SOAP notes must be very extensive. And it must be legible and understandable to claims examiners and insurance auditors as well as attorneys. Many SOAP notes that were considered excellent as recently as 2 years ago would be considered mediocre, at best, and inadequate, possibly indicative for fraud with the new standards that have been established. The answer to this bureaucratic nightmare is an Electronic Health Record system. The bottom line is that Electronic Health Record (EHR) systems are critically essential to the long term survival and growth of your practice.
EHR uses a computer instead of pen and paper. It empowers you to produce a dictation quality SOAP note in a matter of seconds, just by pointing and clicking on the necessary items. The result is a SOAP note that is in English with correct grammar and spelling and contains all the points of information required by law, statute, and policy contracts. Keep in mind that, in most states, and under Medicare, the SOAP note is supposed to be created at the time you are providing the service to the patient, not at a later time. EHR minimizes the time you must spend documenting, so you can concentrate more on patients.
How does this help your practice? A complete EHR system streamlines your practice in many ways, leading to increased income, higher patient visit averages, and greater productivity by your staff. A patient, signed in at the front desk, automatically appears on the doctor’s computer in the adjusting/treatment area. Entering a diagnosis in the documentation end of the EHR instantly places it in the billing area. The services the doctor documents generate the charges for the day as the patient checks out. Since the EHR system is producing the charges based on the SOAP note, the documentation and billing always match. When the patient signs out electronically, the patient’s signature shows that the patient witnessed that the services billed have been provided and that the patient is ultimately responsible for the charges. This provides both audit and collection protection for you.
And, in a personal injury case, you will need narrative reports for attorneys and insurance. EHR systems produce narratives in seconds, pulling the information directly out of the patient file. Thirty-five years ago, when I first began my practice, narrative production was a major challenge, sometimes taking hours to compile all the material. Now, from the time I receive the request, produce the report and send it to the attorney (either fax, e-mail, or printed and stuffed in an envelope) takes 5 minutes or less. EHR systems typically come with narrative templates already built in. Some EHR systems provide you access to the templates, so you can edit and modify them or create your own. Since you get paid for the narrative, and it is the narrative that will make or break the case for you and your patient, it is critical that the narrative provides the substance that enables the attorney to win the case.
Many doctors, when they get busy, will postpone the completion of a SOAP note until a later time.
Many doctors, when they get busy, will postpone the completion of a SOAP note until a later time. For some doctors, “later” never happens. The result is that the note is not produced, even though charges were entered for the patient. If you are one of those “later” doctors, you must now get caught up on your notes ASAP. In order to be sure the SOAP notes are completed, it is imperative to have an EHR system that generates a report listing every patient that has charges but no SOAP note for that specific date of service. This report should be run at least once daily so that the notes are created in a timely manner, while the information is still fresh in your mind. It is important to note that certified EHR systems include an audit log required by the federal government. The audit log tracks every entry, modification and deletion. In the future, when you are using certified software, an auditor or claims examiner will demand to see the audit log. If your notes were created weeks or months after the visit, they will know and charge you with fraud.
When you use EHR as it was designed, it improves the efficiency of you and your staff, eliminates duplicate entries, minimizes the chance of human errors, and increases your income and patient visit average. EHR gives the attorneys the meat and potatoes to win PI cases, and this builds your reputation and practice. The benefits of EHR are available today. Take advantage of them.
Dr. Paul Bindell is a 1975 graduate of Palmer College of Chiropractic, in practice in Rockaway, NJ, since 1976. Dr. Bindell is a past Chairman of Public Relations for the Northern (NJ) Counties Chiropractic Society. In 1991, Dr. Bindell and his family began Life Systems Software so that the profession would have reliable computer programs based on real chiropractic practice. Dr. Bindell is available to speak to your group or organization and can be reached by email at
, or you can call Life Systems Software at 1-800-543-3001.