Best Practices: Problem-Oriented Medical Record and SOAP Notes

In 1968, Lawrence Weed, MD, developed the problem-oriented medical record (POMR) “… to develop a more organized approach to the medical record…” (Weed L. Medical records that guide and teach. NEJM Vol. 278, No. 11 & 12. 1968.) SOAP notes (Subjective, Objective, Assessment, Plan) – although only one component of the entire POMR – have become the standard in clinical record keeping for daily chart notes in ambulatory settings. Proper record keeping using the SOAP method improves patient care and enhances communication between the provider and other parties: claims personnel, peer reviewers, case managers, attorneys, and other physicians or providers who may assume the care of your patients.

The purpose of this post is to review accepted methods of clinical documentation using the SOAP format. CHP does not require, but strongly encourages the use of the SOAP format. If SOAP itself is not used, the elements embodied in SOAP must be recorded.

Basic best practices for SOAP format and other chart notes include:

  • Legibility: Chart notes must be legible, preferably typed. If handwritten, they must be easy-to-read.
  • The provider’s identification (name, address and phone) and patient’s name and unique identifier such as date of birth (DOB) or record number must be indicated on each side of each page of notes.
  • Every chart entry must be dated. Each entry must be signed by the person entering the note (this includes office personnel who make entries in the chart).
  • Standard abbreviations are acceptable as long as they are easily understandable and interpretable by the reader.

There are many styles of chart notes that can be effective. Narrative notes in SOAP format are the clinical standard. Effective chart notes must reflect the four criteria required to document medical necessity.

  1. The patient’s chart must reflect subjective findings that are consistent with a lesion, injury, or condition.
  2. The examination must confirm the existence of a lesion, injury, or condition that is consistent with the patient’s complaints and the exam findings must be documented in the chart.
  3. The management of the case or treatment rendered must be considered appropriate for the condition.
  4. The patient chart should reflect overall improvement over the course of treatment.

The best practices described here are endorsed by many health care organizations, regulatory agencies (e.g., NCQA) and state authorities. Want more information on record keeping or other best practices for integrative healthcare providers? Search “best practices” on this site to read more in this series of articles.

Helping Patients Facing Surgery

Over the last several years, there has been an trend toward patient participation in medical decision-making. Known as “shared decision-making’, this model puts emphasis on involving the patient in their treatment decisions with input from the physician. However, when the patient is faced with the prospect of an invasive medical produce, many feel nervous and anxious; they may have a harder time thinking of questions to ask their provider or surgeon about the procedure and their options.

If one of your patients is scheduled to have surgery or another medical procedure, one way to help them relieve their anxiety about it is to help them learn all they can about the procedure. The following list of questions is based on information from Questions to Ask Your Doctor page on the Agency for Healthcare Research and Quality website. The AHRQ provides basic questions as well as a question generator that patients can use to print a personalized question list.

Encourage patients to use a list of questions like this. They may also benefit from having a family member or a friend at their doctor’s or surgeon’s appointment. Such ones can help speak for your patient and may also be able to help them remember all of the information the doctor or surgeon provides.

Patient Questions
Why do I need surgery?
Find out the purpose of the surgery and how it relates to the diagnosis of your condition. For example, is the procedure designed to relieve pain? Reduce symptoms? Improve function?

What type of surgery are you recommending?
Often, there are different types of surgery available for a given condition. Ask your surgeon to explain the procedure and describe to you exactly what is going to be done. Ask if any instrumentation (hardware such as screws, plates, stents, or cages) will be used and how large your incision will be.

Your surgeon may be able to draw a picture, show you a diagram, give you written information or refer you to other resources such as books, videos, or websites that can help you better understand the procedure.

Are there alternatives to surgery?
For some musculoskeletal conditions, surgery is considered only after conservative, or non-surgical, treatments have been tried. Talk to your surgeon about other options to see if there is any reason to try a different treatment option first or to just postpone surgery. If you have tried various conservative treatments, tell your surgeon about them and why they did or did not help your condition.

What are the benefits of having the operation?
Find out what you will gain from the surgery. Ask how long the benefits will last or if you will need another operation at a later date.

What are the risks of having the operation?
All surgeries carry a risk of complications, such as infection, excessive bleeding, reactions to anesthesia and injury. Be sure you understand all of the possible complications before you agree to have any surgical procedure. Also, talk to your surgeon about any side effects after the surgery, such as swelling, soreness, and pain and how these will be managed. What will my capacity for activity be like?

What if I choose not to have this operation?
After you have learned about the risks, ask your surgeon what would happen if you chose not to have the surgery. Will your condition get worse? Will you have more pain?

Where can I get a second opinion?
Getting another doctor’s opinion about whether or not to have surgery is a great way to ensure you are making the right decision. Many health insurance plans cover getting a second opinion. Call your insurance company to see if your plan will pay for a second opinion.

What has been your experience with this procedure?
Ask your surgeon how many of these surgeries they have performed. Get a feel for their experience with your condition. Ask your surgeon if they can refer you to someone who has also had this operation.

Where will the operation be done?
Most surgeons work out of more than one hospital. Find out where your procedure will be performed. If you have a choice, choose the facility that has the most experience and the highest success rate in treating your condition. Talk to your doctor about whether or not your procedure will require you to stay in the hospital and for how long.

Asking these straight forward questions empowers patients to make collaborative decisions with their caregivers. Empowered patients tend to have better outcomes from any treatment, especially in the case of a major surgery.

Helping Patient Decide in an Evidence-Based World – Part 3

In a previous post, we discussed the need for providers to stay up-to-date on the latest evidence-based medicine so that they can help patients make the best decisions for the healthcare. At the same time, we acknowledged the fact that the sheer volume of material available makes it difficult for providers to keep up-to-date on the latest research. These research tools and databases can assist providers by producing current summaries of the evidence about a wide variety of clinical topics.

TRIP Database –
The TRIP Database is described as a “clinical search engine designed to allow users to quicly and easily find and use high-quality research evidence to support their practice and/or care.” Access to the site is through a free registration. Searches on the database bring up links to the source articles on any particular topic. While TRIP is not focused on integrative healthcare (IH), many topics relevant to an IH practice do include citations of mainstream medical literature that report on such care.

Natural Medicines –
Natural Medicines (formerly Natural Standard) is self-described as the “The most authoritative resource available on dietary supplements, natural medicines, and complementary alternative and integrative therapies.”

For each therapy covered by Natural Medicines, a research team systematically gathers scientific data and expert opinions. Validated rating scales are used to evaluate the quality of available evidence. Easy to understand grading scale and cross-indexing by condition is available to save your time. All data is incorporated into comprehensive monographs which are designed to facilitate clinical decision making. All monographs undergo blinded editorial and peer review prior to inclusion in Natural Medicines databases. In addition to now-familiar symptom checkers and calculators, the NM database offers comparative effectiveness tables, drug/natural medicine interactions and drug and natural medicine depletion guides.

Natural Medicines is “impartial; not supported by any interest group, professional organization or product manufacturer.”

Natural Medicines is a fee-based product. They also offer a free monthly newsletter “covering news and events on herbs, supplements, exercise, nutrition, complementary and alternative medicine modalities, practices, and policy.”

Concussion-Related Migraines in Young Adults

Are you asking your young adult patients about their participation in sports – particularly sports that carry a high risk of concussion? A recent survey presented by the American Headache Society (AHS) at their 57th Annual Scientific Meeting indicates that concussion-related migraines in young athletes are more common than previously thought. If you treat young adults for headaches or migraines it may be useful to inquire about their athletic pursuits as part of your intake questionnaire.

To read the Medscape review of the presentation, please click here.

Helping Patients Decide in an Evidence-Based World – Part 2

In a previous post, we discussed the need for providers to stay up-to-date on the latest evidence-based medicine so that they can help patients make the best decisions for the healthcare. At the same time, we acknowledged the fact that the sheer volume of material available makes it difficult for providers to keep up-to-date on the latest research. These research tools and databases can assist providers by producing current summaries of the evidence about a wide variety of clinical topics.

DynaMed Plus –
According to their website, “DynaMed Plus™ is the clinical reference tool that clinicians go to for answers. Content is written by a world-class team of physicians who synthesize the evidence and provide objective analysis.” Independent studies have ranked DynaMed Plus higher that other clinical reference services in its category.

Ron Lebfvre, DC, of UWS notes, “DynaMed is an example of what some people call pre-digested literature – someone not only reads the primary research but pieces it together almost like a continuously updated textbook. Think of Dynamed as a destination site rather than a search engine looking for research articles.”

Washington-licensed providers may access DynaMed through Heal-WA. Many DynaMed topics include integrative healthcare treatment options. All statements are accompanied by a grading of the supporting evidence. It is interesting to compare the levels of evidence that support integrative healthcare interventions versus conventional medical treatments. Each entry also provides a reference list.

Cochrane Collaboration –

The Cochrane Collaboration is an independent network of researchers, professional, patients, carers and people interested in health that spans the globe. They have over 37,000 contributors that hail from more than 130 countries – all working together to produce health information that is credible, accessible, and free from commercial sponsorship or other conflicts of interest.

Cochrane is useful for anyone who is interested in high-quality health information that can be used to make health decisions – both patients and providers. The site includes editorials, reviews, special collections and evidence summaries. Many of the resources on Cochrane are free to the public and appropriate for patient consumption. The Cochrane Database of Systematic Reviews has free access for many people in low- and middle-income countries and general access licenses available for professionals.

Concussion Recovery Not as Fast as Estimated

A recent study in the British Journal of Sports Medicine indicates that recovery from a concussion might be far longer than previously estimated – by up to 400%! In the study conducted by Anthony Kontos, PhD, researchers noted that athletes took three to four weeks to recover – based on testing and self-reporting for four weeks past the diagnosis of concussion.

To read the Medscape article and the research, click here. (You will need a free Medscape account in order to view this link.)

Helping Patients Decide in an Evidence-Based World – Part 1

The role of providers in clinical decision-making has evolved from “the doctor always knows best” to a more collaborative and shared decision-making process. While some have argued that patients often favor being told what to do by a medical expert, the ethical principle of autonomy acknowledges that patients do indeed have a right for having “nothing about me without me.”

In the world of integrative healthcare, it has long been recognized that patients tend to be more self-actualizing and thus, much more engaged in collaborative healthcare decision-making. Integrative healthcare clinicians typically create therapeutic relationships based on collaboration and “meeting patients where they are…”

Evidence based medicine (EBM) consists of three elements. First and foremost are the patient’s preferences and expectations. Second is the clinician’s skill, experience, and expertise applied to the clinical problem. And the final element is using the best available evidence to make an informed decision. This last element can be a formidable obstacle in that the “evidence” is contained in published scientific and clinical research journals that accumulate at a prodigious rate. An individual in a busy practice obviously cannot keep up with the volume of new research that is published every year.

Fortunately there is a growing presence of clinical knowledge databases that can assist integrative healthcare clinicians in assessing the current state of scientific understanding regarding a variety of clinical questions, diagnostic criteria, and therapeutic options. While most of these are conventional medicine-oriented, some of them do a reasonable job of including integrative healthcare options. These sources use technology to perform continuous literature searches and produce up-to-the-minute summaries of the evidence about a wide variety of clinical topics.

Over the next few weeks we’ll be posting information about a variety of clinical reference tools that can be used by integrative healthcare providers. While most are clinician-focused, some also have content that is developed for a patient audience. In either case these tools can provide information for clinicians to help their patients make clinical decisions. By marrying the patient preferences with the provider’s clinical expertise to interpret the clinical literature together they can make decisions based on the best evidence. This is the practice of patient-centered, evidence based health care.

Can chiropractors really solve the painkiller crisis?

The American Chiropractic Association (ACA) has created an initiative to help curb opioid overdose, misuse, and abuse in the U.S. during National Chiropractic Health Month (NCHM), which is annually in October. There has been increasing volumes of information highlighting the severity of the opioid problem in the United States. A new article on Forbes Magazine website reviews the ACA’s #PainFreeNation initiative which suggests that non-invasive, non-pharmaceutical treatment options should be exhausted before trying medication-based strategies. Some of the alternatives for pain management suggested include acupuncture, yoga, chiropractic, psychotherapy, and physical therapy. Read more at Forbes Health.

More ICD-10 events added in September!

CHP is pleased to announce that we’ve added three more mini-workshops for ICD-10 preparedness to the schedule for September 2015! Check out the registration site here. (Please note that the 9:00 am class on September 3 is already full.) Each class has a maximum capacity of 16 people, so we expect these to fill up quickly. Register today to reserve your seat!

Best Practices: Documenting the Diagnosis in Clinical Record Keeping

The clinical record must contain documentation of the physician’s assessment of the patient’s condition that is being treated.

Documenting the Diagnosis
The diagnosis itself must be consistent with and supported by the patient’s presentation and the examination and laboratory findings. Initially the diagnosis is often only the diagnostic impression or working diagnosis. On follow-up visits the diagnosis should be confirmed as the clinical thought process continues.

Documentation of return follow up visits (usually in the “A” portion of the SOAP note) must include a statement of the diagnosis that reflects changes in the patient’s condition as a response to time, treatment, and other interim events (e.g., “Cervical strain, resolving” or “fatigue, improving”). The “A” should be updated as necessary to be an accurate portrayal of the patient’s present condition.

Diagnosis codes used on a health insurance claim form must be supported by the information in the patient clinical record.

The International Classification of Diseases (ICD) is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics. The ICD-9 was published by the World Health Organization in 1977. The National Center for Health Statistics created an extension of ICD-9 so the system could be used to capture more morbidity data. This extension was called “ICD-9-CM”, with the CM standing for “Clinical Modification”. The International Classification of Diseases, Clinical Modification (ICD-9-CM) is based on the ICD-9 but is used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S. Every health condition can be assigned to a unique category and given a code from ICD-9-CM.

Transition to ICD-10-CM will occur October 1, 2015. Most, but not necessarily all, payers will stop accepting ICD-9 codes and start accepting ICD-10 codes. The diagnosis codes in ICD-10 are more specific and more detailed. For example, left and right side conditions (e.g. extremity conditions) are now two different diagnoses. And there are different diagnoses for certain conditions seen at an initial encounter, in follow up “subsequent” encounters and as a sequela. As with ICD-9 codes, the clinical record must support the code used to document the condition or as used on an insurance claim form.

Note: Some integrative healthcare providers are prohibited by law from making a differential diagnosis. Therefore, this “best practice” recommendation may not apply to acupuncture or massage therapy. However, many diagnosis codes in both ICD-9 and ICD-10 are symptoms only and do not imply that the provider has made a “differential diagnosis.” For example, “neck pain/cervicalgia” is 723.1 (ICD-9) and M54.2 (ICD-10)