Pain in the Ass…essment

Written by Billing Dynamix

Gregg Friedman, DC

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:

  1. Diagnoses
  2. Complicating Factors
  3. 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.

Be BulletProof.