You may have heard the expression, “soap it up.” In healthcare, this expression applies to infection control, but a SOAP note is also a method of documentation used explicitly by medical and dental providers. A SOAP (subjective, objective, assessment, and plan) note writes all the critical information regarding the patient’s health in an organized, clear, and quick manner. Soap notes are found in electronic medical records or patient charts. A common inquiry we receive at Nierman Practice Management from dental practices embarking on their medical billing journey is, “can you send me a template to use for SOAP notes?”. The answer is no; using a canned template for SOAP notes is not recommended! While risking using a prewritten template for SOAP notes may be tempting, you will likely find the inefficiency and opportunity for costly mistakes are not worth it. A dental office that forwards the same boilerplate template of medical necessity to medical insurance companies may find their documentation lacking.
What is a SOAP Note?
To understand why it is not encouraged to use canned templates for SOAP notes, one must first recognize what a SOAP note is:
SOAP notes are the widely accepted format for clinical documentation to ensure a patient’s history, evaluation, diagnosis, and treatment plan are documented and for convenient review by other healthcare professionals and medical insurance companies.
- The subjective portion of the dentist’s SOAP note should include the patient’s chief complaints, and pertinent medical history, noting treatment-specific details such as other therapy attempts and a history of symptoms. Other questionnaire items, such as the Epworth sleepiness scale for patients suffering from sleep-disordered-breathing, or the pain scale for patients suffering from temporomandibular joint (TMJ) disorders, become part of the individual SOAP note.
- The objective portion of the dentist’s SOAP note should include tangible data, including but not limited to vital signs, exam findings (i.e., oral, airway, TMJ), laboratory reports, imaging results, or any diagnostic conclusions.
- The assessment portion of the dentist’s SOAP is, in short, the diagnosis. Remember that ICD-10 medical diagnosis codes confirm not only diseases but also conditions, symptoms, and situations.
- The plan portion of the dentist’s SOAP note should outline the treatment plan. Examples include recommended diagnostic testing and procedures, medications, referrals to other healthcare professionals, and patient education details.
For a SOAP note to be considered comprehensive or complete, the patient’s subjective (symptoms) and objective information (exam findings) lead to creating the patient-specific assessment and plan. Herein lies why it is not recommended to use templates for SOAP notes: each patient is unique, and the SOAP note should document each patient’s distinctive medical history, exam, diagnosis, and treatment plan.
Why Record Cloning is a Problem
A significant consideration on this topic is record cloning. According to the Centers for Medicare & Medicaid Services (CMS), “this practice involves copying and pasting previously recorded information from a prior note into a new note, and it is a problem in health care institutions.” CMS also indicates that “the medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter.” Furthermore, another insurer states, “cloned documentation does not meet medical necessity requirements for coverage of services.” A template for SOAP notes may cause a health professional to inadvertently perform data cloning without realizing it. This can result in an unfavorable outcome in the event of a records review or audit by a medical insurer.
SOAP Notes are Helpful
Okay, now we know everything there is to know about SOAP notes. They’re helpful because they give you a simple method to capture your patient information fast and consistently. A great way to create SOAP reports is by asking the patient to submit chief complaints of medical necessity and health history online. A dedicated software system can generate a SOAP note from the treatment-specific questionnaire and exam forms to the patient’s unique situation and treatment plan when billing medical insurance in dentistry. For example, when billing medical insurance, utilize specific questionnaires for obstructive sleep apnea screenings, TMJ pain consults, or oral surgery cases. It is equally important to look for ease for the dentist to document the evaluation, diagnosis, and treatment plan with a system that emphasizes the ICD-10 diagnosis codes and CPT procedure codes.
Dental practices enjoy the ease of utilizing the DentalWriter Plus software to generate documentation of medical necessity and such as SOAP Notes. The goal is to help make medical billing in dentistry EASY for our clients.
To learn more about the do’s and don’ts of medical billing, explore our upcoming dental courses in medical billing for dentistry (both in-person courses and online courses available). Nierman Practice Management also offers Nierman Medical Billing Services to help dental practices with all their medical billing needs. Nierman simplifies medical billing in dentistry, allowing dentists to stay focused on the patient work, while we do the paperwork. Learn more here.
Author: Courtney Snow