Home Forums Discussions General Discussion A basic question.....SOAP notes

After some months of (intermittent) research, including reading this forum, I have decided to move ahead with implementing an EMR. I haven't finalized my decision, but I expect to commit to Amazing Charts and purchase it in coming weeks. By way of background, before I start with the questions....I am a solo gastroenterologist with outsourced billing, so my needs are pretty basic. I need an EMR and scheduler, with the ability to provide superbills and demos to my biller. In addition, reading the board here has made me look forward to a paperless office (somewhere down the road). My situation is a bit unusual in that my wife is an internist who is not currently practicing. She is now managing the conversion to an EMR, and will then start to see patients; so AC has to work for her, too.
I gather from reading some previous posts that the experts here prefer to receive questions in small "bites" so I will start with a little one: How do I make a plain old SOAP note? I understand the process for a full note that includes the CC, HPI, ROS, etc, but how about if I just want "subjective, objective, assessment and plan" as my headings?

Hey, don't pay for AC yet. You can use it free for 3 months. Use it on a few patients a day. Get up to speed and then go for it when you are comfortable.

I don't use SOAP notes, so I'll let someone else field your 1st question.

You can't.

Bert,
Thanks for the reply...even if you are telling me what I would rather not hear.

So does this mean:
1. EVERY note AC produces must have the cc, hpi, ros, etc? Even if you put nothing in the box, you still get the heading?
2. There is no way to customize the headings?

I suppose this puts me into "wish list" territory. Seems to me it would be nice to be able to alter this. For example, aside from SOAP notes, as a GI, the program could be used to produce procedure reports very easily, if the headings could only be changed.

If you wanted to use SOAP format, maybe you could setup a template in the "Assessment" field. I would still use the Chief complaint field for the encounter name and then just fill out the "assessment" field following your subjective, objective, assessment and plan format. We do something similar for hospital encounters that are documented in the hospital's EMR system rather than our AC db. In these instances, our AC record is only used for billing purposes.

Renaming fields in the entry form probably would not be feasible as the AC database expects certain data to be entered in those fields. But adding a custom report the wish list that shows only the assessment field (your SOAP note) may be viable.

Eric please don't get angry with me. But, while that would work, and I just tried it, it does leave the issue of having SH, PMH, etc. still there, and the note looks terrible.

Jon, Not completely sure what you're looking for, but I once made my own mini EMR if you want to call it that and used HotDocs to create it. There is a bit of a learning curve, but to this day, it is the best formatted note I have seen second only to Logician Internet, which is no longer in existence. I can send you a note to show you what it looks like (if I can find one). But, you wouldn't have the power of the EMR.

Using only the cc and assessment fields looks sparse that is for sure. Just a quick & simple workaround, not necessarily pretty.

Bert, thanks for breaking the news to Eric, so I don't have to.

What am I looking for? Well, I am new at this, so I naively want the EMR to fit my practice pattern, rather than the other way around. So, when I do a consultation, the note has all the headings listed in an AC note. But for follow-up visits, I would create a SOAP note for the record and the referring doctor. I was hoping to continue that practice, but I suppose I cannot with AC.

Is that really different from what everyone else does/did????

I don't know what everyone else does, but I doubt many do.

Since you are a GI, do you need to send a return letter to each referring physician? Maybe you could make a template (or several) in a SOAP format in AC's Letter Writer, and the letter would be saved as your visit documentation in Imported Items, and also generate a letter to your referring doc.

Funny you mention that. I was working on the same thing. Unfortunately, AC won't allow tables to be made into templates, so you could easily have a template.

If he was to do that, couldn't he use the addendum window to create SOAP templates? That would still pull up the letter writer IIRC. The only draw back is an addendum is thought of as being in addition to the last encounter. If AC were to change the layout of the program to show addendums below or to the side of the chart it wouldn't look or be right.

I think these are all good ideas. But, the lack of flexibility in making usable templates, makes me wonder if just having a good one in Word and using it independently of AC. Then save it and import it.

As a specialist I know what you mean. There is a SOAP note in AC though. I put the subjective in the HPI, the Objective in the Physical Exam and the A/P in the A/P. Sign the note and the encounter/letter writer pops up. One of the option is SOAP note with or without your practice header. It puts the stuff in order of SOAP. I then "Print" it to my fax machine (i.e. referring doc).

If you like a letter to the referring doc as well as your note, just go to the letter writer, write a letter and include a copy of your note when faxing it to them.

This has worked outstanding for me in my vast 7 weeks of AC experience. My Family Practice docs, who I've just met since I'm new in town, have told me how much they appreciate having the note so quickly so they know what I've decided to do with the patient.

Thanks for all the ideas.

More about "where I am coming from"....as a specialist, I have heard many complaints in recent months from referring docs (mostly internists and FP's) along these lines: "I hate the notes Dr. Specialist sends since he/she got an EMR. I used to get a 1/2 page SOAP note that told me what they thought. Now I get 2 pages that is mostly reiterated stuff that I already know (like FH, SH, and a 5 system ROS) and a load of diagnostic codes that I don't even want. The information I need is buried in the note and I have to work to find it!" So that is what I want to avoid.

Bert, it sounds like you (and I presume 99% of other AC users) have a family history, social history, etc, in EVERY follow-up note. Is that really your preference? Do you do that to improve reimbursement to allow upcoding? I can't imagine you did that in the pre-EMR days when you wrote or typed your notes....

I hope these questions don't sound aggressive or hostile. Believe me, I very much appreciate your willingness to share your information (about AC and in general). I would never presume to argue against your practices; I just want to better understand them and how they might apply to me.

Travis, if you have 7 weeks of AC experience that puts you about 6 weeks and 6 days ahead of me. I will try your suggestion, but won't that still leave me with the "ROS/SH/FH" headings with nothing after them?

John, your idea seems (to this overwhelmed mind) to have the most promise, but I am not familiar enough with the letter writer to see how functional this would be. I guess the idea is to keep all the information (FH, etc) in the NOTE which is good for coding purposes, but to create a "letter"--which would actually be the SOAP note--to send to the referring doc. It is just a ? of how many extra clicks and pastes this would take.

Again, thanks to all for the help....

Jon,

Welcome to AC. And, I am sure I speak for all when I say I appreciate your thoughts about making follow up notes so easy to read. A lot of my consultants are still dictating so it hasn't been an issue. Some still write, and I don't even read those -- can't.

Logician as we have talked about on here before is the worst for what you are mentioning. It is based solely on reimbursement and documenting everything. As you know, technically when I make a note and it says PMH: Asthma, it shouldn't count toward E & M unless I say I addressed it again. AC has that build it with a preference, but it makes the note look kinda bulky.

To be honest, I never really thought about how AC sets up the note compared to my writing days. Plus, most of my notes aren't really follow-ups, they are new issues, although I do have some follow-ups.

One of the things that AC is lacking (IMO) is a lack of options or preferences. My programmer tells me that options are not easy to code.

Although I suggested the Letter Writer, after thinking about the comments above, I think JBS's easiest way to SOAP his notes is what Ben suggested -- using the Addendum option as the encounter note.

The Addendum is automatically dated and when saved, becomes part of the list of past encounters. JBS can make several templates for common conditions for each of the S, O, A & P components and right click to add them to the Addendum field and then edit to create the notes. On the next visit, he could open a prior encounter from the past encounters tab and cut & paste what he wants to repeat, and then use templates or edit further in the new addendum field for the new note.

Since the Addendum field is just a big empty space, anything fits.

Jon, if you use the SOAP note format, it will only use those headings (subjective, objective, assessment, plan). I just send my referring providers a generic letter format with my A/P hooked onto the end. Takes 20 seconds to zip it to them without any extra work.

You could just "print" them a SOAP note by printing it to your fax machine.

When I first started practice before AC, I would dictate my note, then dictate my letter to the referring provider. I would then read over those quickly, sign them, and then have my staff fax the letter to the referring provider, file the note/H&P, and file a copy of the note to the referring provider. It was a process and cost me an arm and a leg in dictation costs.

Now, my staff enters in all of the info except for HPI (very few templates), PE (standard template), A/P (a lot of templates), which I do. It's slower than dictating but it speeds up dramatically the longer you do it. I sign that and fax a quick letter with my A/P at the bottom to the referring provider. I often have to fax my H&P to the place where I may do a procedure or operation. All of this takes less than one minute to do after the actual note is done. I do it all but I could easily have my staff do it. I'm just a control freak and don't mind the extra 10 minutes out of my day.

I have yet to finish my day without all of my notes being done by 5pm, all the letters sent to referring providers, and the H&P sitting at the hospital for the operation.

I'm close to recouping the cost of the program by not using paper, folders, dictation costs, and staff time in just 7 weeks.

Travis,

Nice post! You are correct about the soap format, but it still includes drug allergies and medications as well, doesn't it?

Bert,

It only puts the allergies and medications in there if you have them in your note. It lists them under the Subjective part of the note.

If you use a blank note template with each follow-up then all you have to do is enter whatever you want in the Subjective in the HPI, Objective in the physical exam, and A/P in A/P. It works great for we dumb specialists who don't use the medications and allergies all the time and don't need that sent to our referring docs with every follow up.

LOL,

You dumb specialists keep us know everything about everything but not enough about everything in business. So, that brings up a question I have always wanted to ask (now I have been drinking here, so give me some slack).

But, if I call a specialist on the phone, I may talk to him/her then or three days later, and I feel like I have to ask my question in one minute or less and always feel as if he or she is doing me a favor.

On the other hand when he or she calls me, he or she will get me in under 30 seconds every time.

Just wondering what your perspective was. Of course, I am in Bangor where there is very little competition.

I feel like chiming in on this one, but it's an old story oft told..... We primary care types are the Rodney Dangerfields of medicine but not paid as well as Rodney.

Jon, S.

As a Primary Care dweeb, I am tickled to death when I see a note from a specialist that has the PMH, SH, Meds, and Allergies noted. That tells me that the specialist took the time to truly evaluate my patient and that he/she knows more about the patient than just that they have a sick gall bladder. Attaching a short personal letter to your office encounter note would be more than enough to make me feel good about having referred to you. When you say the referring docs are upset with the notes they get now "that you have that new EMR" makes me think they are just jealous that you can produce just a clean and complete record. So, from my perspective, your notes are fine. But if you really want to make me mad, have your ARNP sign it!!


Leslie
Yes, I'm back

Leslie,
Glad to see you back.
The SOAP note is nice ( but not something to fall on a sword about)and could be a template in the addendum. It will show up in the visit history perfectly well just like a past encounter does.
The games you are describing (Bert) are probably not restricted to doctors with big egos, I bet lawyers and bankers play those games too. Some people have gray hair but still behave like a juvenile.

Thanks for the input from all. I will respond in detail when I have had a bit of time to take it all in, and to play with these ideas.

Leslie, I guarantee there is no jealousy involved-many of the internists share the same EMR (provided to hospital employed docs)and they know the info is just regurgitated back, rather than painstakingsly documented by the specialist.

In the meantime, my office staff has instructions that if a pediatrician named Bert calls from Maine, to put him right through.....

Jon, can I get that number... lol.

@Deborah...I would never compare a doctor to a lawyer. Doctors tend to work for their money.

Plus, I am not so much complaining as wanting to get a specialist's perspective.

Oh, and if someone took my note out of context, when I said "dumb specialist" I was quoting Travis. Whew.

Just to re-visit this after having time to use the program for awhile: Travis is exactly right; an easy way to do notes in a SOAP format is already built into AC. It works just as he described it so well above. Maybe this should be in the "Tips" section of the board. And also in that AC User's manual that I somehow never got a copy of.