Good SOAP Notes and Efficient EMRs

There are many EMR software programs to help physicians create SOAP notes after each patient visit. SOAP notes allow doctors to record a patient’s complaints, objective measures to identify the complaints, the assessment of the complaints including diagnosis and prognosis, and the plan to help remedy the patient’s complaint. Doctors have been recording patient visits for a very long time and from the beginning it was done with paper charts. Since the advent of the computer and internet and the advancement of technology, it has become easier to document a patient's visit. These innovations have also allowed health records to be sent to other places for reference to other physicians with the click of a mouse. In the past, these records needed to either be mailed or faxed. In both circumstances, it was easy for sensitive information to be intercepted or sent to the wrong places. EMRs have helped that become less of a problem because it can be encrypted or sent through protected email. 

It is still vital to a physician and their license that good notes and records are complete in order to prevent errors in care which could lead to problematic outcomes. It is also important because, in the event that another physician continues to care for a patient, they can look back at previous treatments for future care. It also behooves a doctor to have adequate notes so that they are compliant with local and federal law when it comes to their scope of practice and what is allowed by their respective state laws. Not being compliant or even fraudulent in the documentation of a patient can lead to serious repercussions. Appropriately billing the procedures and therapies for a patient is also documented and recorded for insurance. Lack of compliance is either negligence or fraud and neither is looked well upon. 

Ask any doctor or physician if they like to do charting or notes and almost everyone will say no. It is time-consuming and sometimes monotonous. As people who are inclined to solve problems, it is natural to want to solve this dilemma of something that is time-consuming and boring. And so the quickest way is to copy and paste past visits and record them as new visits with dates changed and not much else until there is a re-exam or re-evaluation.

The biggest drawback with copying and pasting SOAP notes from one date of service to the next is the potential to forget previous objective measures. For example, a patient may come in for the first time to an office. The doctor performs a complete history and exam with orthopedic tests and range of motion findings, including adjustments to the restricted segmental spinal levels. At the next visit, if the doctor were to select “same as last visit”, every subjective and objective finding, as well as the assessment, will be copied to the new visit. This essentially shows that nothing has changed from one visit to the next, but that is not the reality because nothing is ever the same with healthcare.

Personal injury claims and insurance claims can be rejected because of copied notes, not to mention it violates sound ethical practices. An insurance adjuster or an independent medical examiner may look at records and notice that notes being copied at each visit would be grounds to deny claims and personal injury cases would hold up less in court or mediation. Even more to the doctor's detriment would be if the patient were to be asked if those things were performed at each visit and they were to say “no”, then that would negate almost every visit after the patient was initially seen.

At ChiroSOAP this isn’t the case. A doctor has the ability to create notes that accurately convey what a patient is experiencing that day they are seen as well as new objective findings. A patient doesn’t feel the same at every visit nor is any objective finding the same. ChiroSOAP allows a doctor to pull diagnoses and subjective complaints from previous visits all while allowing changes to be made to subjective and objective findings on the fly. This creates notes that are unique to every visit for every patient, every time.

ChiroSOAP also allows a doctor to correlate the objective findings to specific diagnoses so that there is little room for insurance to deny claims. Showing that a positive anterior drawer test will directly match the correct diagnosis of an ACL tear of the knee. Just like a Valsalva maneuver coupled with Milgram’s test will positively show complete objective findings for a diagnosis of lumbar disc pathology.

The verbiage and language used in the completed notes in ChiroSOAP are not run-of-the-mill, general, and vague. Instead, each subjective complaint, range of motion finding, orthopedic test, palpatory finding, and spinal or extremity adjustment will be noted to have a correspondence to a diagnosis. This gets to the heart of making notes simple and fast without complicating the process and eliminating repetitiveness. 

ChiroSOAP is also very user-friendly and intuitive. A physician is able to create a SOAP note at the same time they are seeing a patient and be finished by the time the patient leaves the office. The ability to use a mobile device is what makes ChiroSOAP special. Instead of clicking and moving a mouse on a computer screen you just tap on the appropriate tabs and box and ChiroSOAP does the rest. Anything that may be unique to a patient or a visit in general can be dictated or typed for convenience and reference because not every patient visit is the same and neither is every visit the same for each patient. Having the ability to finish a note by the time a patient leaves a treatment room is where ChiroSOAP shines. With less time wasted between patients or long after hours of finishing notes a doctor can have more time with patients, see more patients in a day, and even have more time with their family and friends after work hours.

Just as a hypothetical, let's say that you forgot to chart your last patient of the week and you didn’t remember until you got home or even the next morning of your precious weekend. No worries here because you can pull up ChiroSOAP on your phone, input your notes for that patient and be on with your weekend without the fear of having to wait until the following Monday to go to the office and try and remember what was done for that patient on that visit.

ChiroSOAP has other features that make it a better option for an EMR system. It comes with a scheduler so that you can see your schedule for the day, week, and month without changing programs from the scheduler to an EMR. It is a seamless transition from one to the other without changing tabs in your browser.

ChiroSOAP also comes with built-in billing that automatically fills out health insurance claim forms based on your input from each tab of the note. This makes billing a breeze and less of a headache for a biller in the office.

Lastly, reminders can be added within a patient’s file so that a doctor can remember that the patient was recently on vacation or they have osteoporosis or a vertebral fusion. Any reminder so that a doctor doesn’t need to remember everything about every patient.

It is clear that ChiroSOAP makes the life of a physician much easier by avoiding repetitiveness and monotony without sacrificing efficiency. Isn’t it better to spend more time with patients and have more time with patients and have good notes rather than spend time grueling over making good notes and less time with patients? ChiroSOAP is the answer.