Subjective, objective, assessment, and plan. Any way you look at these words, they add up to something very important for you and your practice. Better known as SOAP notes, these are the records you implement when documenting patient encounters. From the time your patient walks in the door, to their experience in the treatment room, and ultimately as their file hits the billing desk, tracking a patient’s flow through your office is the key to keeping you safe from a dreaded insurance audit.

An expensive way to stay clean?

A myriad of documentation software is available for DCs to choose from, some with more features than the latest Maserati. Others offer modules that you can pick from to create your own system, while bare bones offerings provide plain and simple solutions to keep you above water – for now. In any case, it pays to purchase not only the system that is right for you, but one that will protect you from future mistakes that could cost you your practice.

How then, does a little SOAP do your practice good? By documenting what is happening in your practice in a timely and accurate manner. A good system will take your notes - whether written by hand on a tablet or tapped into a PDA with a stylus - and turn them into legible documentation that flows naturally and lends itself to easy access and analysis for reports. But how can you measure whether this is really helping you or not?

One manufacturer offers a return-on-investment report that looks at items you have billed, your collections and how much time your staff is spending on paperwork management. This particular report notes that by implementing a SOAP notes software program, that a practice can save more than $1,000 in staff salaries, reduce your investment in time by $1,700, and increase your collections by almost $3,700—per month.

Another way that a SOAP notes system helps you is by reminding you to bill for items that you may have forgotten about. With this in mind, it’s easy to see why the initial outlay of cash for a good documentation system is petty change compared to the actual savings garnered by putting it into use.

Wash away the worries
The SOAP notes documentation solution that you choose should ideally integrate with its own or other vendors’ billing software. This allows for continuity and creates a complete, worry-free record that can face an insurance audit.

When your documentation does not match your billing, insurance red flags fly into high gear, putting your entire practice at risk, as well as yourself. There are horror stories about DCs who were required to refund insurance carriers hundreds of thousands of dollars because a mere handful of files did not match what the carrier was billed for. This is because the insurer assumed that if the handful did not match, then the whole lot didn’t either. Inadequate SOAP documentation, unfortunately, is ruining many more practices than it used to because of the increasing requirement for electronic health records, further necessitating that you seriously consider a software solution now.

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