Anatomy in Action Series: The Alphabet Soup in Doctors' Notes
Laurie Mueller
BA, DC, CFMP
Taking Note of the Notes
Great note-taking is crucial for every patient. Doctors of chiropractic (DCs) refer back to notes from previous visits not only to evaluate treatment plans but also to track the progress that patients are making and to review their symptoms and any adjustments prescribed.
Third-party payers, like insurance companies or Medicare, may also ask for copies of notes when they audit accounts or evaluate patient care for reimbursement. Third-party payers may also have very specific components that need to be included in the notes. Notes may also be subpoenaed by law offices for litigation in court cases involving accidents, personal injury, or injuries on the job (work comp).
At the end of the day, the DC is responsible for taking excellent notes and the accuracy of what is in each patient's file. In some offices CAs may assist DCs in the treatment rooms by entering information in the notes that the DC verbally dictates during patient care. CAs may also be on the frontline when third parties request notes and when daily files are being reviewed. CAs can help their DCs by scanning files and ensuring that notes are complete before refiling and by flagging daily files for the DC to review and update if a daily note needs to be fully completed. Ideally, notes are completed at the time of the patient visit; however, sometime during a very busy patient-care schedule, the DC may choose to use shorthand during the visit and complete some of the notes later in the day.
SOAPs that Are Squeaky Clean
During each patient's visit, the DC will go through the S.O.A.P. process for the notes. SOAPs are a standard format employed across a broad range of fields in healthcare with different patient/client care objectives. They provide a consistent, organized structure that everyone is familiar with. This acronym stands for the following:
S = Subjective: This includes specific patient symptoms and how the patient describes their current state of health to the DC. A scale of 0-10 is often used as the patient is asked if the condition is better, worse, or the same. Details regarding their pain would then be recorded. For new conditions, details of OPQRST would also go here.
O-Onset: How did the pain start? What was the patient doing?
P-Provokes/Palliates: What makes the pain better or worse?
Q-Quality: What does the pain feel like? (sharp, dull, throbbing, electric, numb, tingling, etc.) R-Radiates: Can you point to where the pain is? Does the pain go anywhere from there? (E.g., low back pain on the right next to L5 but it shoots down the leg.)
S-Severity: How bad is your pain? On a scale of 0-10 with zero being no pain and 10 being the worst pain. This rating is subjective and based on how the patient perceives his or her own pain. T-Timing: When did the pain start? Is the pain constant or intermittent? How often does the pain come and go.
O = Objective: These findings are measurable data that can be substantiated through the examination. Orthopedic and neurological examination findings are recorded here. The DC may find muscle spasm, for example, asymmetry, can assess reflexes, range of motion, palpatory pain, swelling/tissue changes, and can assess levels of the spine that exhibit fixation along with specific planes of the fixation.
A = Assessment: This is where the DC enters a diagnosis or, if the diagnosis is unclear, enters a list of differential diagnosis (what condition they may be suspected in the order of most to least probable). The DC will also include an appraisal of the patient's progress.
P = Plan: The plan outlines what the chiropractor will do to address and manage the patient's condition. It should include elements such as adjustments (may include levels and specific fixation planes), if physiotherapy active or passive care is utilized (if so, which exercises, repetitions, etc. With modalities include which one/s and what settings duration.) Lab testing, referrals, lifestyle modifications or other services are provided. Plans to continue treatment and when/if you will follow-up with the patient, or if the patient is being discharged are all elements to be included in a plan.
Streamlining
Some offices opt for hand-written notes. A wide variety of effective software tools are available that can help streamline the process of note-taking, which can be especially helpful for busy offices. They can also be beneficial for third party entities like Medicare. The rules for note-taking with Medicare are particularly strict. Their specific guidelines require that the records document specific subluxation levels and symptoms that have a direct relationship to those levels. If your office uses an electronic health record system (EHR), it is highly recommended that CAs train to understand how to use it effectively.
Also beneficial (whether hand-writing, typing, or using an EHR) is to understand a bit of the shorthand
commonly used in SOAP notes. Talk to your DC and ask what abbreviations they use the most. A few of those abbreviations include, but are certainly not limited to, the following:
b/c
B
CC
c/o
d/t
Dx
Ed
EMS
F/U
HPI
HA
IVD
ROM
Hx
Because
Bilateral (both sides)
Chief complaint
Complained of
Due to
Diagnosis or diag-
nostic test
Education
Electric Muscle
Stimulation
Follow-up
History of present
illness
Headache
Intervertebral disc
Range of motion
History
L
Min
Mod
Max
Mx
R
R/O
Rx
Sx
w/
w/o
C
T
L
LS
Left
Minimum
Moderate
Maximum
Monitor or monitoring test
Right
Rule out
Treatments
Symptoms
With
Without
Increased
Decreased
Cervical
Thoracic
Lumbar
Lumbosacral
Education Fosters Understanding
An understanding of clinical applicability helps CAs better assist in the office, communicate with patients, and provide care more safely. Discover coursework designed for CAs at www.cccaonline.com and use AMCHIRO as your discount code during the registration process to automatically provide a $15 discount off the regular price of the program.
Laurie Mueller, BA, DC, CFMP served in private practice in San Diego, California. She was the post-graduate director at Palmer College from 2000-2010; served as the ACC Post Graduate subcommittee chair for 6 years; peer reviewed for the Research Agenda Conference, and wrote the informal role determination study that aided in the development of FCLB's guidelines for chiropractic assistants (CCCAs). Dr. Mueller currently works as a private eLearning consultant with a focus on healthcare topics and functional medicine through her company, Impact Writing Solutions LLC, and subsidiaries www.CCCAonline.com and www. fxmedonline.com . She is a clinician, an educator and an expert in online educational pedagogy.
References
1. https://www.emsl.com/ems-products/education/articles/how-to-use-opqrst-as-an-effective-patient-assessment-tool-yd2KWgJIBdtd7D5T/
2. https://chiro.org/Graphics_Box_LINKS/GUIDELINES/Wisconsin/Chapter_Vl.shtml
3. https://owl.purdue.edu/owl/subject_specific_writing/ healthcare writing/soap notes/index.html
