In the webinar Quick & Compliant Daily Notes, Dr. John Davila clearly explained why notetaking must shift from focusing on a patient’s pain level in order for SOAP notes to be faster, more compliant, and more effective.
In Part I of the webinar recap, he explained that Medicare’s denial rate ranges from 60 -100% today. This is because documentation expectations have changed, but our note-taking processes have not. It’s now the patient’s response to care that’s key to documentation, so it’s important to note levels of function rather than levels of pain. SOAP notes today need to center around the question “What can’t you do today that you could do before you hurt yourself?”
Function and endurance become the goal with documentation, which better helps you get patients to where they want to be. When notes are based on a patient’s level of pain, it looks like Days Of Our Lives. The patient has pain on every visit, and there’s pain on visit 90. It’s one long soap opera, and you can’t tell where it begins or ends which makes it almost impossible to respond to documentation requests properly.
But insurance companies now want to see subjective stability as a measurement of MMI (maximum medical improvement.) They pay to make symptoms stable. This is why a pain based documentation system doesn’t work, and why you need to create one based on what policy requires.
The insurance company expects to see a certain patient profile, but when your notes don’t match that profile, there’s no reimbursement. Especially in a cash-based practice, this makes for very unhappy patients.
Think of your SOAP notes like a Tom Clancy novel. You only need to read one of his books to know what will happen in the others. Jack Ryan saves the world in all of them. Your notes should also all be the same—repeatable.
For example, Mrs. Johnson can’t walk up 10 flights of stairs due to back pain, but with treatment she’s able to walk up 10 flights of stairs, the end. It’s all about wellness care, wellness care, wellness care, and showing improved function even if the pain is the same.
That’s the first step in changing your documentation process, then you need to talk about the connection. PART, as we know, stands for pain, asymmetry, range of motion, and tissue or tonal change. But if you ask a patient “how’s your asymmetry” they don’t know what you’re talking about. You need to change the language to be more complaint, noting posture, range of motion, spasm or swelling. Then create a diagnosis based on those measurements and set up a treatment plan that can measure and document changes in each. The key is to understand that each one of these four findings equals a diagnosis.
Diagnosis codes have really changed, and now it’s all about “showing your work,” much like a math problem. You must show the background that supports each diagnosis code.
In PART, you could say a patient has a complaint in the spine area, a posture deficit, and spasms in the back. You have to say what you found and how it relates to the diagnosis codes.
This is all important because when you go to build the treatment plan you can tie each finding to an improved-function goal.
You need to have both short and long term goals for each patient, so you can adapt the plan as you go along. If you don’t write your notes as goals it becomes impossible to know when to say “when.” You need to create a plan to go from active care to wellness care, and do that for each goal.
Then, take notes based upon the patient’s condition, whether it’s active care or wellness care. Create notes that differentiate between the two so that you don’t have to take active care notes for wellness care patients. A wellness care note documents that there’s no loss of function.
Again, it all comes down to function based notes, which are more compliant, effective, and accurate.
The benefit of Platinum System EHR software is that you can customize the notes to be function based. The software is designed to make notetaking so much faster and more compliant. If you’d like to view Dr. John Davila’s webinar Quick & Compliant Daily Notes, click here.
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