The Pitfalls of "Same as Last Treatment" Approach in Medical Documentation

The Problem with “Same As Last Treatment”

The biggest drawback with using a system that essentially “copies and pastes” SOAP notes from one date of service to the next is the potential to forget previous objective measures. For instance, say a patient comes in for the first time to an office. The doctor does a complete exam with orthopedic tests and range of motion findings, including adjustments to the restricted segmental spinal levels. On 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. Virtually showing that the last visit was the exact same as the previous visit.

This creates big problems when it comes to insurance claims, personal injury claims and overall sound ethical practices. If someone from the outside, say an insurance adjuster or an independent medical examiner, were to look at the records they would see that many visits over a period of time having the exact same notes being completed at every patient visit then it would raise some eyebrows. 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 because not every visit does a patient feel the same 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.