Update on Physician SOAP Notes

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An Encore Presentation

By Dr. David Edward Marcinko MBA

[Editor-in-Chief]

www.BusinessofMedicalPractice.com

DEM 2013I wrote on this topic previously. Both as primary paper driven SOAP notes, and as next-gen electronic SOAPier notes, to much acclaim and derision.

  • Why? Because, now more than ever, inadequately documented medical charts can mean civil and criminal liability to the sloppy and/or unwary practitioner. And, medical records were previously used to aid in the quality of medical care.

Today, they are also the basis for payment for services, not as a record or reflection of the care that was actually provided, but as a separate justification for billing.

What is a SOAP Note?

SOAP notes

Assessment

SOAP[IER] eMRs [Beware the Alphabet Soup Switcher-Roo]

Conclusion

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3 Responses

  1. Why I hate the SOAP note

    An essay by Suzanne Koven MD.

    http://www.kevinmd.com/blog/2012/11/hate-soap-note.html

    Ann Miller RN MHA

  2. More on SOAP Notes and eHRs

    We must demand a return to meaningful notes.

    http://www.kevinmd.com/blog/2013/08/demand-return-meaningful-notes.html

    An essay by Robert Centor MD.

    Ann Miller RN MHA

  3. Does the SOAP note still fit in the age of EHRs?

    Some physicians are opting to put the assessment and plan pieces before subjective and objective findings.

    http://www.medicalpracticeinsider.com/news/does-soap-note-still-fit-age-ehrs?email=MARCINKOADVISORS@MSN.COM&GroupID=90115

    However, that sequence makes the progress note too provider-centered, according to the doctor who created the traditional format.

    Ann Miller RN MHA

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