10-Point SOAP Note Checklist

by Marty Kotlar, DC, CPCO, CBCS • 

President of Target Coding • 

Question:

Dr. Kotlar, I do not think my SOAP notes would pass an insurance audit. How do I know if they’re good enough? What can I do to ensure SOAP note compliance?

Answer:

To begin with, the main objective of Subjective, Objective, Assessment Plan notes is to document the entire encounter, regardless of patient clinical condition or financial ability to pay. I’ve heard some doctors say, “I adjusted the shoulder, but didn’t document it because the patient’s insurance doesn’t pay for it.” This is not the correct thought process.

Whether you document in an electronic health record, on paper, or dictate your notes, most likely at some point in your career, you’ll make an error and/or omit documentation in the record for that treatment visit. When this occurs, clearly identify any amendment, correction, or delayed entry as such, indicate the date and author of any amendment, correction, or delayed entry, and identify all original content, without deletion.

If a change to paper records is required, use a single-line strike-through, so the original content is still readable, and the author of the alteration must sign and date the revision. For paper records, amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record. EMR records containing amendments, corrections, or delayed entries must distinctly identify any amendment, correction, or delayed entry and provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.

Here’s my 10-Point SOAP Note Checklist to ensure compliant documentation:

1. Make sure every page of your SOAP notes clearly lists your name, address, e-mail, and telephone number.
2. Make sure the patient’s name is legible. You may need to assign an account/file number to every patient. Check with your state board.
3. Enter the date the service was rendered, not the date the note was signed. The notes should be completed and entered into the patient record on the day the service was rendered.
4. List all the symptoms/signs the patient verbally states, writes, or digitally enters into your EHR system. Document all items such as pain scales, frequency of pain, what has occurred since the last visit, etc. (S)
5. Document any additional items provided by the patient. For example, “this is the first time in 6 months I do not have numbness in my right hand.” (S)
6. Document the examination findings. To document a subluxation, Medicare recommends the P.A.R.T. method. Make sure your documentation and objective findings satisfy the P.A.R.T. method subluxation requirements. (O)

• Pain/Tenderness: The perception of pain and tenderness should be documented in terms of location, quality, and intensity.
• Asymmetry/Misalignment: This may be identified on a sectional or segmental level through one or more of the following: observation (posture and gait analysis), static palpation for misalignment of vertebral segments, diagnostic imaging, etc.
• Range of Motion Abnormality: Changes in active, passive, and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility. Range of motion abnormalities may be identified through one or more of the following: motion palpation, observation, stress diagnostic imaging, range of motion measurements(s), etc.
• Tissue Tone, Texture, Temperature Abnormality: Changes in the characteristics of contiguous and associated soft tissues, including skin, fascia, muscle, and ligament, may be identified through one or more of the following procedures: observation, palpation, use of instrumentation, tests and length and strength, etc.

7. The assessment provides an opportunity to provide an impression of what’s ahead for the patient based on the present status. Report any significant changes to the short or long-term goals. Document recommendations for additional testing, and/or treatment plan revisions, etc. Describe when and why the next re-evaluation should be performed. Describe any significant changes in status relative to each goal currently being addressed in the treatment plan. Assessment of improvement, extent of progress (or lack thereof) toward each planned clinical goal. Plans for continuation of treatment or anticipated discharge date. Did the patient meet a goal? Are they making progress towards the goals? Did any measurement get better?  The assessment provides the chance to update the link between the patient-identified functional limitations and the measured impairments. Are the present diagnoses (ICD-10) and procedures (CPT) still appropriate? Examples, a) Patient is now able to put on shoes and socks without assistance, b) The patients ability to sit at computer is now up to 45 minutes without pain. Originally it was only 10 minutes, c) The patient is improving better that expected, d) The patient is not responding well to care and will be sent for additional testing (e.g., MRI, EMG, Neurologic consultation), e) The patient has responded very well to care, has achieved maximum therapeutic benefit and will be discharged from active treatment next week. (A)
8. List every procedural service/product provided to the patient. List the specific bones that are being adjusted/manipulated. List the specifics for every modality/therapeutic procedure provided (e.g., time, anatomic location, muscles, protocols). (P)
9. Doctor must electronically sign or provide a hand-written signature on the date the service was rendered. The chart notes must identify the provider/staff member responsible for the care of the patient.
10. Enter the date the service was rendered.

Good quality patient care involves documenting everything that occurs during every patient encounter. Good documentation is essential if your files are ever asked to be reviewed by an insurance company, state board, or malpractice case or if the patient simply asks for a copy of their notes. Good documentation is the only way for you to substantiate that the care you provided was actually performed.

Email info@targetcoding.com to receive a FREE Sample SOAP Note.

Dr. Marty Kotlar is the President of Target Coding. Over the last 12 years, he has helped hundreds of chiropractors, physical therapists, and acupuncturists with compliance as it relates to billing, coding, documentation, Medicare & HIPAA. Dr. Kotlar is certified in compliance, a certified coding specialist, a contributing author to many coding and compliance journals, and a guest speaker at many state association conventions. He can be reached at 1-800-270-7044, website – www.TargetCoding.com, email – drkotlar@targetcoding.com.