When we document a SOAP note, there’s one part of it that most doctors are doing partially right, but are missing a HUGE piece. I’m talking about the… Assessment
There are three parts of the Assessment:
- Complicating Factors
- How is Each Condition Responding Since the Previous Visit
For the diagnoses, make sure you document the codes and descriptions, not one or the other. Complicating factors, which are not a requirement, can be very helpful, since they add context to possible reasons why the patient may be responding more slowly than expected. Instead of documenting a generic batch of complicating factors, it’s much more powerful to document complicating factors that are specific to each symptom that we’re treating.
But … Here’s the Big One
This last one is the big cahuna. How is each condition responding since the previous visit? This is actually a Medicare requirement and has been coming up in audits. They want us to compare today’s complaints/findings to what they were on the last visit. They want us to actually go back to the last visit and compare to today’s visit. Almost ALL of the records I review, though, fail at this. I do it automatically.
Because I use metrics in my documentation, I use technology to do all the “looking back” for me. If the neck pain intensity is a 6/10 today, but it was a 7/10 two days ago, my SOAP note will not just say that the neck pain intensity is improved since the prior visit, but that it’s improved by 14% since the prior visit. If the low back pain frequency is noted as 40% of awake time today, but it was 70% of awake time on the prior visit, my SOAP note will not just say that the frequency of the low back pain is improved, but it’s improved by 43%.
Tell the Patient
As good as it is for me to see the metric improvement for my patients, I think it’s just as important to let the patient understand how much they’re improving.