My daily SOAP notes start to look the same after about visit 24. The patient still relates problems to me, but it seems as though I am writing the same information down every time. How do I make sure my notes can prove medical necessity, even on the 85th visit?

To answer this, let’s begin with general guidelines for SOAAP notes (note, the extra “A” for Activity of Daily Living).

S stands for the history of subjective complaints. These subjective complains include:

O stands for objective findings from your examination. Examples include:

A stands for the activities of daily living evaluation, such as:

A also stands for the assessment. Examples include:

P stands for the plan of treatment, such as:

Chiropractic care is considered medically necessary when your documentation can show that your treatment is expected to improve (significantly) or resolve a condition and continued care will result in functional

Once the clinical status stabilizes, without expectation of additional objective clinical improvements, further chiropractic care is considered maintenance.

Most chiropractors prefer spending time helping their patients rather than filling out forms. However, one of the responsibilities of running a successful chiropractic office is ensuring that you record the services you provide so that you can receive proper reimbursement.

SET GOALS

When you complete your initial evaluation, write down goals for the patient and establish a feasible timeline in which to reach these goals. The biggest mistake chiropractors make is setting goals that are not objective, quantifiable, or functional.

Make your daily notes brief, but intermittently relate to your patient’s initial goals. Instead of simply writing “Initial goals continue to be realistic,” write, “Goals will be met in six more visits” or “Treatment will be extended for two more weeks.”

Also, add information such as, “The prescribed low-back exercises were too painful and had to be eliminated.” Then explain the activities you will do with the patient.

In short, your daily notes need to support the charges, and your weekly notes need to address progress toward the patient’s goals.

Submit claims to insurance companies as long as you feel you can prove medical necessity, this might be for eight visits, 50 visits or even 85 visits — as long you can show medical necessity.

Marty Kotlar, DC, CHCC, is the president of Target Coding Inc. He is certified in healthcare compliance and has been helping chiropractors optimize insurance reimbursement through proper and compliant CPT coding since 1992. He can be reached at 800-270-7044, www.TargetCoding.com, or by email at drkotlar@targetcoding.com.