Patients who beg for the ultrasound or X-ray tech tell them what’s wrong don’t understand that the art of assessment is what separates a physician from a technician—but doctors do.
And it doesn’t just come into play when testing and technology are involved.
The assessment portion of the initial findings is where everything comes together as you gather evidence and formulate your conclusions about the problems that each patient is presenting and how to address them.
Understanding the SOA equation
Despite common belief, the assessment is not simply a diagnosis and treatment plan, though both play a role in its formation. It’s actually more than that; it is your opportunity to demonstrate your expertise using the evidence in front of you.
Therefore, the assessment is a key element in both your treatment and reimbursement outcomes.
The assessment is where you consider everything the patient has said (the subjective information) and everything found in the exam (the objective data). To that, you add the results obtained from outcomes assessment tools (OATs) and your diagnosis, rendered from a combination of subjective and objective data.
Finally, you add your clinical experience, expertise, and everything known about the case on every level to produce your clinical assessment of the patient’s condition.
Initial assessment should be a part of every evaluation and management (E/M) service that begins a course of care with a new or existing patient, as well as those re-evaluations and new- condition evaluations when the patient is entering a new or different episode of care.
The assessment (A) is derived from what you learn in the subjective (S) history and objective (O) examination portions of the visit. The equation is thus stated as S + O = A. The assessment is a concise statement that includes the particulars of this patient and his or her condition, and it outlines for a third-party payer exactly what is going on with the patient, why it is happening, and how the patient’s condition is similar to or different from other related cases.
This simple addition to the record can make the difference between care that gets approved for a few token visits and care that meets medical necessity guidelines and tells a clear, easy-to- grasp story of the patient and the episode of care.
The following are important aspects of the initial assessment to be taken into consideration.
Interpret the facts — don’t add new ones
The assessment is not the right place in the initial notes to introduce objective facts (especially new ones) about the case. Instead, this is where your opinion about those facts should be outlined and delineated.
Your clinical opinion about the findings adds weight to the tone of the documentation. Your professional opinion is valuable and therefore needs be found in the documentation.
Include comorbidities that may cause the patient to need a longer treatment plan. Take this opportunity in the E/M note to state your findings in a simple, succinct manner that makes for a compelling addition to the initial visit documentation.
Justify the diagnosis and treatment plan
Because the initial visit notes outline the diagnosis and plan for care, the assessment supports your decision- making with professional judgments about the diagnosis, plan of care, and prognosis. The assessment must use the patient reporting, measurements, complicating and comorbidity factors, test results, and any unusual circumstances to paint a clear picture of the plan of care. It’s also important to include any contraindications to care— or lack thereof—that have been considered.
Support case management
The initial assessment is also the first opportunity in your notes to demonstrate case management. It’s here that you express your rationale for treatment options and how the patient will likely respond to care. This is where you outline how this patient may be different from others with similar diagnoses or conditions.
Prognostic factors such as type of work, psychosocial factors and emotional state, previous episodes, and lifestyle habits can affect one patient differently from another. The assessment is the place that a third-party payer will understand this patient’s unique presentation and circumstances.
Learn by example
Strive to customize the initial assessment to the patient and the situation in front of you for maximum effective- ness in your documentation. Elaborate on the assessment with documentation of your diagnosis and treatment plan in detail to really make it shine.
Here is an example of a simple, straightforward assessment:
Based on the information available, I believe that Mrs. Jones is suffering from cervical radiculitis. Her case is complicated because she is of advanced age and her recent fall down the stairs was traumatic, both of which factors will likely result in a slower response to care. There are no obvious contraindications to beginning conservative care. A trial of care will be initiated for four weeks, and she will be seen three times per week until re-evaluation. The goal of treatment is to bring her grip strength in her left hand from 8 kg (poor) to 22 kg (WNL) within this timeframe. Her progress will be monitored closely and changes will be made as necessary.
This analysis, which takes into account different elements of the case, is the difference between an X-ray tech looking at a film and thinking, “Yeah, that could be a fracture there,” and an experienced doctor analyzing a patient’s circumstances, gait, responsiveness to tests and analysis tools, and ability to comply with treatment.
Doctors aren’t magicians and they aren’t technicians either. When your initial assessment shows your depth and breadth of skill and experience, both the patient and your reimbursement are better for it.
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and Certified Chiropractic Professional Coder (CCPC), and since 1983, has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. She leads a team of 20 at KMC University, and is known as one of the profession’s foremost experts on Medicare. She or any of her team members can be reached at (855) 832-6562 or info@KMCUniversity.com.