Academy of Chiropractic

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From the Desk of Dr. Mark Studin
Academy of Chiropractic

Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006

“Don't Destroy Your Reputation with SOAP Format in an E&M Report”

 

 

“Perception is reality” Mark Studin 2021
 

Evaluation and Management [E&M] reports are a powerful tool, a point that is too often overlooked.  They are either initial encounters or your mandatory 30-day evaluation reports. This reporting type is required to get reimbursed for services rendered and ensure your safety regarding compliance against fraud allegations. One of the most overlooked areas of an E&M report is reputation.

Your reputation is driven more so by what you put on paper than any other form of communication in health care. This conversation is focused on your referral sources and the reputation your reports create. If your reputation “oozes” confidence in your diagnosis, prognosis, and treatment plan along with management of your case in a possible collaborative environment, then you stand a much greater chance of receiving referrals from the recipients of your reports.

When was the last time you received the report from an orthopedic surgeon, a neurosurgeon, or a neurologist in soap note format? The answer is never. When you send a report in a soap note format, it makes you look like an uneducated technician. Physical therapists, whose notes are often excellent, utilized this format. You have now lowered yourself to the level of a “non-doctor.” the biggest problem here is that medical specialists already have more confidence in the physical therapy profession as a rule than they do in chiropractic. You are merely “fueling” that dogmatic perception and significantly injuring your reputation.

Some EHR systems automatically default E&M reports to a soap note format. Most of them give you the option to bypass a solo format and use a more traditional way of reporting your evaluatory findings. If your EHR does not allow you a traditional way of reporting, you must change your EHR no matter the “pain” process. Please note this is not a compliance issue as soap note formatting on an initial evaluation and reevaluations does not create any potential legal issues; it can, however, destroy your practice over time.

EHR systems typically retain compliance consultants that understand only half the picture. They are appropriately focused on regulatory compliance; however, very few understand the entire practice concept and how to integrate being compliant while ensuring your reputation as both an expert and peer to medical specialists.

Your reports should be sent regularly, as a matter of business, to lawyers, medical primaries, medical specialists, insurance companies after your evaluatory encounter on every patient. This is a double-edged sword as if you use the improper soap format; it will injure your reputation in practice. However, if your reports are in the appropriate “traditional format” that every lawyer and medical provider is used to seeing throughout their entire career, it will enhance your reputation as an expert and peer with medical specialists.

These actions are a very strong piece of the puzzle in the referral process and are NON-NEGOTIABLE.

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