Last yi-ar, nil-: Office of tiii; In-spector General (OIG) of the U.S. Department of Health and Human Services (HHS) stated that about 57 percent of all payments to Doctors of Chiropractic in 2001 did not meet the coverage criteria. With this finding, commercial carriers are now auditing and demanding refunds which, in turn, cause the doctors to become financially distraught. When a patient walks through your clinic doors, what goes through your mind? Do you say to yourself, "Oh great, this is going to be easy because this patient is a CASH patient!" or, "Oh no, this is going to be a lot of work with taking notes because this is a personal injury or workers compensation patient." Most chiropractors believe that their notes should be more expansive for a personal injury or workers compensation case. This just isn't true unless, of course, you're not taking proper notes on your cash and commercial insurance patients in the first place. The notes that you take with your personal injury patients and workers compensation patients are the same as any other patient, with the exception that you may want to be choosier with your diagnosis and your treatment plans should have some well-defined GOAL in mind. Your CASH patient needs to have notes taken on them as well because, if for no other reason and if you read this article no further, then let me state this, "Your CASH patient can sue you just as easily as your third party insurance patient!!" Another thing that you should take away from this article is the fact that medical necessity does not come from your SOAP notes. Medical necessity comes from the diagnostic tests that you perform. The daily SOAP notes are only intended to state what happened that day. According to the federal government (Medicare Carriers Manual December 1999. section 2251.2), the particulars that should be included in the SOAP notes are shown for the initial and subsequent visits in Tables A and B respectively. TABLE A. ITIAL VISIT HISTORY The history in the record should include: Date of the initial treatment; Symptoms causing patient to seek treatment; Family history, if relevant; Past health history; Mechanism of trauma; Quality and character of symptoms/problem; Onset, duration, intensity, frequency, location, and radiation of symptoms; Aggravating or relieving factors; Prior interventions, treatments, medications, secondary complaints. EVALUATION • Visual Inspection • Area of chief complaint • Posture/Gait • Orthopedic/Neurological tests • Orthopedic tests, ROM test, Muscle Test, DTR's, Dermatomes; • Palpation/Percussion. DIAGNOSIS TREATMENT PLAN • Duration & Frequency of visits; • Specific treatment goals; • OBJECTIVE measures that measure treatment effectiveness: • Computerized ROM testing, computerized muscle testing, algometry, questionnaires, X-ray, CT, MRI results. Example: Patient: John Doe Date: November 15th, 2005 S: Mr. Doe is a 27-year-old gentleman of black descent who appears to be uncomfortable. He stated that he exercises frequently. He denies the use of alcohol and also denies the use of tobacco. He is currently a student athlete and descends from Ethiopia. He is 6 foot 0 inches tall and weighs 150 lbs. He related a past history of similar problems which occurred approximately one year ago. Past treatment included manipulation. No diagnostic tests have been performed for this condition. He has had no past treatment for this particular problem. Today, Mr. Doe describes having episodic moderate lower back symptoms which are achy, dull, sore and stiff in character. This was experienced gradually after he had been running in college and he felt, after the last few training sessions, that he had a very sore back and his knee was getting very sore as well. O: The patient was alert and oriented to place, person and time. Memory was intact and there was no evidence of any speech disorder. His right-sided BP was 118/82. On active range of motion testing in the lumbar region, extension was painful but unrestricted. All other active lumbar ranges of motion were normal. Bechterew Sitting Test, Kemp's test, Soto Hall Test, Valsalva, Ely's, FAbERE-Patrick, Hibb's test, Millgrams, Nachlas, sacroiliac stretch, Supine SLR and Yeoman's were negative bilaterally. All of the standard lower extremity muscle strengths were graded 5/5. The lower extremity dermatomes were found to be unremarkable. All of the lower extremities DTR's were 2/2. On palpation, mild to moderate spasm and tenderness were observed in the lumbar region bilaterally, the U-L5 paraspinal musculature bilaterally and the sacroiliac area bilaterally. On digital palpation, moderate spasm and tenderness were found in the quadriceps and the gastrocnemius. All active right knee ranges of motion were normal. A: Patient tolerated treatment well. The primary diagnosis is lumbalgia (724.2) with associated lumbar somatic dysfunction (739.3) which is complicated by scoliosis-idiopathic (737.30). The second diagnosis is knee inflammation (716.96) with associated pelvic obliquity (738.6) which is complicated by myospasm (728.85). P: The purpose of care is to reduce his pain, reduce joint fixations and reduce inflammation of the musculature. Additionally, care will be provided to increase his ranges of motion. The treatment schedule will be daily for a few visits and then three times per week for one month. This case will be reevaluated in 12 visits. cRom testing was performed, diversified adjustments to C1, C5 seated, T1 prone. Low volt surge therapy to quadratus lumborum B/L for 10 min. Modalities performed to the right knee consisted of continuous ultrasound at 1.0 w/cm2 for 10 minutes. Patient is to return tomorrow. Ice was recommended for residual soreness from treatment. (Refer to ICE handout). cMT will be performed next visit. ■f TABLE B. HISTORY • Review of Chief Complaint; • Changes since last visit; • Systems review, if relevant. UBSEQUENT VISIT PHYSICAL EXAMINATION • Exam of area of spine involved in diagnosis; • Assessment of change in patient condition since previous visit; • Evaluation of treatment effectiveness. DOCUMENTION OF TREATMENT GIVEN THAT DAY Example: Patient: John Doe Date: November 16th, 2005 S: Mr. Doe related that his low back pain has not changed and that his knee pain has been better. O: The objective findings are improving. A: On spinal evaluation, joint dysfunctions were noted in the cervical spine, the thoracic area, the lumbar region and the pelvis. The same diagnosis applies. P: I will maintain the current treatment regimen so long as progress remains constant. If his progress slows or stalls, I will reevaluate to determine further options. The cervical spine, the lumbar spine, the thoracic spine and the pelvis were manipulated using diversified technique. L5, L4, the right sacroiliac joint and the left sacroiliac joint were manipulated side posture and T8, T7, T6 and T5 were manipulated prone. Today, modalities applied to the right knee consisted of continuous ultrasound at 1.0 w/cm2 for 10 minutes. Today's treatment was tolerated well. His next visit is in 1 day. The above examples would allow me to get paid at a Detailed E/M Level for my initial note, and the subsequent visit would be paid in full. These two notes would allow any doctor to step into my clinic and be able to treat the patient in a professional manner by being able to administer the treatment without having to ask the patient to describe what treatment they receive. When I am teaching the Evidence Based Chiropractic Seminar Series, the one question that I am consistently asked is what I would consider the best and most appropriate SOAP note system. What 1 can tell you is that treatment/travel cards are not notes and they should not be used as such. Some practice management consultants teach a treatment card SOAP note system and only that. This is not correct. You want to use a system the insurance industry understands; after all, they are the ones holding your checks. So use what they are used to and understand. The best SOAP note system is dictation. Dictated notes are the best note system for any practice. They are legible and they don't sound canned. However, the largest drawback with dictation is the cost, as insurance reimbursements have not kept pace with inflation, and the price of dictation is increasing and becoming less affordable. My personal recommendation for dictation software is Dragon NaturallySpeaking. I use this software for my letters and even this article. It takes about fifteen minutes to get you up and running and the headset and microphone that come with it are perfect. The only thing that I don't like is that 1 have to keep a number of MS word files on my computer and it is a small hassle in organizing the patient notes. The only recommendation that I make for software is DC Powernotes. This is the most supreme software for Chiropractic Continued on pg. 59 Are YOU Ready for an AUDIT by Dwight Whynot, D.C. Continued from pg. 43 SOAP notes anywhere. I like the fact that you can customize the heck out of it. The more you use it, the faster you become in creating a note. 1 love how it organizes the notes and that you can print off a single note or the entire record in a matter of mouse clicks. It also contains a radiographic report writer as well. The notes do sound a bit canned, after reading an entire record; but they are still notes and they do explain what happened that day. I have never had a problem with the use of DC Powernotes in a legal situation or otherwise. I have actually been complimented on the thoroughness of the DC Powernotes from auditors. So, don't get caught with your pants down around your ankles in the SOAP note department. Take pride in your notes. Your notes are a reflection of your practice. If your notes are sloppy and illegible, it reflects poorly on you. Poorly written notes make you look unorganized and you become an easy target for audits and the witness stand in a legal situation. If they are well-written, legible, with concise statements, you look organized and less likely to be hassled regarding the specifics of the notes. There is no short cut to proper note taking. Dr. Dwighi Whynot is a successful full-time private practitioner in Johnson City, Tennessee and a graduate of Logan College with a bachelor's degree from Dalhousie University, Nova Scotia, Canada. Dr. Whynot gives license-renewal lectures on Evidence-Based Chiropractic Practices which are promoted by the EBC Seminars and sponsored bv Myo-Logic and Spinal Logic Diagnostics. Dr. Whynot also gives license-renewal lectures to the medical community in Tennessee. For questions regarding evidence-based practice procedures, [email protected]. For6 and 12 hours CCE license renewal lecture dates and locations call Karl Parker Seminars at 1-888-437-5275 or visit www.EBCSeininars.com.
