Episode 2: SOAP Notes with Dr. Warren Jahn

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Dr. Joshua Eldridge: Welcome to episode two of the ChiroPractice Pro podcast. This is part one of a two-part series on SOAP note documentation. As a group of providers, one of our biggest struggles is producing SOAP notes and documentation that meets the legal standard and stands up to an audit with flying colors. In today’s episode, we discuss quality SOAP notes structure with Dr. Warren Jahn. Dr. Jahn has earned three diplomates including orthopedics, sports, and forensics. Forensics is the application of medical facts to legal issues.

In this capacity, Dr. Jahn has reviewed tens of thousands of notes, has consulted on hundreds of audits and has been an expert witness in many court proceedings. He understands what happens in audits and he’ll help your notes meet the standard when it comes to documentation. We’ve put together an example SOAP note for you as well as SOAP note quick tip sheet available in our show notes at chiropracticepro.com/episode2.

Dr. Joshua Eldridge: Welcome to episode two of the ChiroPractice Pro podcast. This is part one of a two-part series on SOAP note documentation. As a group of providers, one of our biggest struggles is producing SOAP notes and documentation that meets the legal standard and stands up to an audit with flying colors. In today’s episode, we discuss quality SOAP notes structure with Dr. Warren Jahn. Dr. Jahn has earned three diplomates including orthopedics, sports, and forensics. Forensics is the application of medical facts to legal issues.

In this capacity, Dr. Jahn has reviewed tens of thousands of notes, has consulted on hundreds of audits and has been an expert witness in many court proceedings. He understands what happens in audits and he’ll help your notes meet the standard when it comes to documentation. We’ve put together an example SOAP note for you as well as SOAP note quick tip sheet available in our show notes at chiropracticepro.com/episode2.

Now here’s our special guest, Dr. Warren Jahn. Hi, Warren, welcome to the ChiroPractice Pro podcast. I’m really excited to have you here with us, because you’re a mentor for me. You’ve taught me a ton about SOAP notes and about documentation. Thank you for coming and being part of the ChiroPractice Pro podcast.

Dr. Warren Jahn: You’re welcome.

Dr. Joshua Eldridge: All right, so tell me a little bit about how’d you get started in chiropractic and your journey through this whole healthcare thing?

Dr. Warren Jahn: Well, I was a jock in Seton Hall University. I was a baseball player originally and the oldest of seven kids. When I went to try out for the baseball team, I never saw a batting unit, so obviously, I didn’t make the team. I went down to the gym and I saw this game that some older gentleman was playing and it looked like he had a badminton racket. He says, “Would you like to try it?” And I said, “Sure.”

He was a priest and he was the head of the squash team at Seton Hall. Long story short, I ended up as a walk-on, being on the team. It came to the spring and he asked me, “What are you gonna do now?” I said, “What do you mean?” He says, “Well, I only can give you a half of a year scholarship because you’re in only one sport, got to have something else.” So I said, “Well, I only know baseball.” He says, “Well, how about tennis?” I didn’t even have a tennis racket, so obviously he gave me a tennis racket. At the end of my senior year, I was running 13th in the East Coast and the number one doubles team on Seton Hall.

But through that all, I got hurt, pulled some muscles especially a hamstring muscle, and I learned how to work with athletic trainers. Back then, it was ice cold whirlpool baths, and of course, we did a lot of taping. That’s how I started in sports. Then from there, I went to chiropractic school. I was a pre-med major in Biology and Chemistry, did not want to go to research. I had a cousin who was in the FBI in Chicago and one that was in the fire department. Obviously, that’s where I ended up going, National University of Health Sciences.

From there, completed the four years and thought musculoskeletal conditions in orthopedics was the thing to do, and I became one of the first orthopedic residents in Chiropractic. One thing led to another, here I am. I’ve obtained three board certifications, Chiropractic Orthopedics, Sports, and Forensics. Forensics is the application of medical facts to legal issues or proceedings. Working in that arena, I reviewed tens of thousands of medical records from all different providers and that’s how I know about SOAP note.

Dr. Joshua Eldridge: That’s where we jump into the meat of this. What is a progress note, and what’s the purpose of a SOAP note?

Dr. Warren Jahn: Well, progress notes are the essential in documenting changes over time that can be crucial to your diagnosis and management. The SOAP note format, and it’s an acronym for Subjective, Objective, Assessment and Plan is a method of documentation employed by healthcare professionals to write out notes in a patient’s chart. The SOAP note format was originated from a book called the Problem Oriented Medical Record which was developed by Lawrence Weed who was an MD.

He just passed away in June of last year. We can thank him for at least coming up with SOAP notes. It was initially developed for doctors who at the time, 1964, were the only healthcare providers allowed to write in a medical record. The format gained popularity with the medical community throughout the ’70s, it did take that long. Today it is widely adopted as a communication tool between healthcare providers as a way to document the patient’s progress.

Dr. Joshua Eldridge: Now, let’s get into the structure of the SOAP note, and let’s start off with the Subjective. What are we looking to do with the Subjective, and how is that part of the progress note?

Dr. Warren Jahn: All right. Subjective in simple terms is any information you receive from the patient. It could be a history of the present illness, past medical history, response to last treatment, changes in symptoms, new symptoms, pain scale, or pain drawing, other outcome tools are updated serially and any changes in activities of daily living or ADL performance. Anything the patient may say pertaining to his or her condition is subject. Once you get that, then the components of the Subjective is a detailed narrative format that describes the patient’s self-report of their current status in terms of their function, disability, symptoms, and history. It’s comparing the last note or encounter to this new note. It will be an update and include anything the patient reports that have changed since the last encounter.

Maybe the pain was radiating as far as the lower leg, and now it’s only to the knee, or maybe the patient fell down the stairs and aggravated a prior injury. It may also include information from the family or caregivers, and if exact phrasing is used, should be included in quotation marks. Sometimes the patient doesn’t remember, and maybe the spouse is there, and say, “Oh, dear you don’t remember, but this is what happened.” It allows you, the provider, to document the patient’s perception of their condition as it relates to their progress in rehabilitation, functional performance, or quality of life. This is the subject area, comes from the patient about how they feel, how they’re doing. In certain times, did you do the exercise that we gave you? Did you sit in a proper way? Did you put heat on it that we told you to do? That’s the information on Subjective.

Dr. Joshua Eldridge: When we’re doing the Subjective, especially in an EMR, are there things that we can automatically fill out? Say, we don’t want to do it the same as last, is that correct?

Dr. Warren Jahn: Correct.

Dr. Joshua Eldridge: Because then, we’re not getting what the patient actually says. In a SOAP note, are there portions that we can move over from the previous note that would then be okay, like if you’re talking about your outcome measurement scores or things of that nature that haven’t changed on this visit?

Dr. Warren Jahn: Yes. Things like where the pain is, is it radiating, is it not radiating. The certain components of where’s the pain, what’s the pain, how is it reacting, those things will certainly be in there so you can modify from one note to the other. Outcome assessment tools are done serial. You’ll always want to keep them there so that if you have initial one on the first visit, and maybe 2 weeks or 10 visits later, you’re doing another one, you can compare them instantaneously because it’s there. Remember, other people are going to look at that. Anything that shows progress or change is the important thing in the progress note or SOAP formatted note.

Dr. Joshua Eldridge: That’s the thing I want to make sure people know is that you don’t have to spend six hours doing one SOAP note. We can make it quickly, but we have to have great stuff in there.

Dr. Warren Jahn: Correct, but here’s the other part. If you use the note from before, it gives you the things that you got to ask for. Now, I’ve got to know where it is, what it is, where did it change, et cetera. It’s already there, you’re just modifying each one of those things to update it from the previous encounter.

Dr. Joshua Eldridge: If you could see the information, you could say, “Hey, I’m going to change this based on what the patient said today or how they’re feeling.”

Dr. Warren Jahn: Correct, and you got to ask them about those things because that’s the most important. That’s really why you put it in there.

Dr. Joshua Eldridge: Okay, sounds good. Now, let’s move on to the Objective. What’s the whole purpose of the Objective? Does the Objective part drive other parts of the note?

Dr. Warren Jahn: Yeah, the Objective component or findings from the provider’s viewpoint. These are objective observations of the condition, the details, all the information and factors that can be measured, seen, heard, touched, felt or smelled. If there are diagnostic exams or procedures that have been conducted, it is documented in this section. This usually has some of the same information on the physical exam.

Things like visual observations, postural analysis, palpable findings like hypertonic spasm, listings that you’re manipulating, test results such as let’s say you did range of motion findings, you redo them again, there’s a change that would be included here. Any neurological test, orthopedic test and a lot of times, it’s formatted, the section is formatted identically as your initial encounter or re-exam.

Those are the things that’ll show you progress that you’re interested in. For instance, if I have a patient with lower back pain and leg pain because of radiculopathy, I need to know is there sensation changes, reflexes and that needs to be done on every visit because neurological component of that lower back pain is the most important thing I want to monitor. Often, the only difference between the notes from time to time is the brevity of the information.

As in the Subjective component, many times only the changes since the last visit will be noted. While concise detail is important in every component of the SOAP formatted note, it’s particularly critical for the Objective component. The information provided in this section may form much of the foundation for the decision made regarding the patient’s diagnosis and treatment plan, and should be accurate and focused. The provider should avoid writing down broad summaries or generalizations here.

Dr. Joshua Eldridge: What would be a broad summary or generalization?

Dr. Warren Jahn: Increase range of motion rather than saying, “I measured it and it increased by seven degrees in right lateral flexion.”

Dr. Joshua Eldridge: There’s one question I had too, something while I was going a note today. Can I compare my objective today in the objective finding to my previous objective? Can I say, “Straight leg raise was 35 degrees of hip flexion on a previous visit, today it’s 45 degrees.” Is that something I put in my note today, or is that something I’d leave out?

Dr. Warren Jahn: No, that’s what you want to put in. Everything that shows progress. If I have a straight leg raised to let’s say your example, 35 and it goes to 45 or 50, that shows progress, so yes that’s important to put in there.

Dr. Joshua Eldridge: Do I put the finding today, or do I put it in comparison to the last visit?

Dr. Warren Jahn: I would just do today’s. When you do a re-exam, down the line, you’ll be comparing the results of the initial exam to the re-exam or the re-exam prior to that. That’s where you’ll see the differences in there, but on a daily basis, that would be great to see that it’s going on there. Here’s the problem with that. Guys do ranges of motion, but they never really measure it. They look at it, or whatever it is. And they never have it in any other ending digit other than 0 or 5. You can’t have a 22, you can’t have a 28. It looks like everything is just 5’s and 0’s as you go down, not very good when you’re getting an audit.

This section also, the Objective section, lists any pertinent new medical records received, imaging or laboratory data. I’m a big proponent of requesting medical records from any patient that comes into the office. First of all, you’re going to learn a lot, you’re going to find out all the diseases that they have or conditions that they never told you about because they thought you’re only a chiropractor and that’s important for you. If you read the stuff, you’ll be a better note-taker because now you’re learning what other providers do, and you can use it.

Dr. Joshua Eldridge: Which is how I’ve kind of gotten better is because I got to read your notes on a daily basis. It’s definitely helped for sure. Do you have anything else about the Objective? I feel pretty good about that.

Dr. Warren Jahn: It’s pretty good.

Dr. Joshua Eldridge: All right and how often should we be doing the Objective part, like a re-exam? We talked about that before. When should we add that in?

Dr. Warren Jahn: It’s really your preference, but the overall consensus if you look at some of the guidelines, a re-exam should be done a minimum every 30 to 45 days. Initially maybe after 6 visits, 10 visits, but within a 30 to 45 day period, you must do a re-exam in order to take or get reimbursed, or whatever you’re going to do with the information for anything that follows.

Dr. Joshua Eldridge: So, you’ve got a patient that comes in that you do your re-exam, you compare it to your initial exam and they’re the same, the patient isn’t improving. What do you do and how do you document that?

Dr. Warren Jahn: Well, you document it as your findings. What I would do is I’m also going to do serial outcome tools at the same time, whether there’s pain drawing, VAS, I particularly like the neck and back Bournemouth objective or assessment tools. I’m going to compare it to that too. If there’s no change, I need to do this, a new diagnosis and/or change treatment. I will do that for two weeks, four visits, six visits, whatever it is, and then re-examine. At that point, if it’s exactly the same from the first and second re-exams, then I’ve got to either refer the patient, there’s something else going on that I don’t know about, imaging, whatever it might be.

Dr. Joshua Eldridge: Now, why do you like the Bournemouth exam? Why do you think that is?

Dr. Warren Jahn: It’s a good indication, there’s only seven questions on it. It not only includes certain clinical stuff, but the two main things that I find is number four and number five that talk about anxiety and depression. Most of our musculoskeletal patients have anxiety and depression. When you have those things, they have to be listed as comorbidities.

Comorbidities are anything that’s going to stop you from progressing in the normal treatment way, whether it’s age or they have other conditions, diabetes, hypertension, whatever it might be, but anxiety and depression are important to address in order to get them. In the sports world, we call it fear avoidance, in some of the armed services, they’re going to call it fear avoidance, “Hey I don’t want to do it. I think I’m going to get hurt more.” That type of thing. Most of the time with musculoskeletal, you got to be more active, not lay down and not do anything, but be more active and perform your rehab to get you going.

Dr. Joshua Eldridge: When you have a patient that comes in out in private practice and they have this fear avoidance, they have anxiety and they’re not improving, how do you deal with that and how you deal with that with the patient?

Dr. Warren Jahn: Well, I will make a referral to psychologists to try, or actually either that directly if I have that connection or back to the PCM or a primary care doc, family doc and say, “This is what I found, do you have anybody that you can refer him to?”

Dr. Joshua Eldridge: That’s also a good marketing tool for you to use with that doc.

Dr. Warren Jahn: Totally, anything that you get referrals and anything that you can tie into a referral source or for you to expand your referral source, that would be great.

Dr. Joshua Eldridge: All right, and how do you explain it to the patient without telling them that they’re crazy, how do you let them know, “Hey, this is why you’re not improving.”

Dr. Warren Jahn: I would go to their daily anxiety portion first. I’ll say, “You’re really frustrated with this, aren’t you?” Remember the open-ended and the closed-ended question? “What do you feel?” “Oh, my wife’s on my butt all the time. I just can’t do it. or my job is, I hate my supervisor, and I just don’t want to go back because I know he’s doesn’t care what the doctor says, or whatever orders he’s given me for a temporary total disability. I’m just going to do it,  so I won’t come in.” That’s how you’re gonna do it.

Dr. Joshua Eldridge: You’re finding out their story and what’s going on behind the scenes.

Dr. Warren Jahn: Exactly, because those are the things that you have to pull out of the patient.

Dr. Joshua Eldridge: Then you just say, “Hey, I understand what you’re going through. I’ve got this great colleague who deals with these type of things, or I want you to go back and just discuss this with your PCM.”

Dr. Warren Jahn: Right or, “I need for you to talk to somebody other than at home. Always have somebody else to help you. Are you open to that?” “Yes, I am.” “Okay, well here you go. This is who I’m going to recommend.” or I’ll have the staff call and say, “Let’s get you an appointment right now.” That’s okay.

Dr. Joshua Eldridge: Okay, would you do something more like that if you had a friend or a colleague that was a psychologist, and they’re ranking their depression 8, 9, 10 on the Bournemouth, is that something that you’d want to see a referral right away?

Dr. Warren Jahn: I want to see anything that’s 7, 8, 9 or 10. You can break it down to 1, 2, 3, 4, 5, 6, but anything 7 and above, that’s when I start being alerted. If on the serial things, that doesn’t go down because they’re feeling better, there’s an issue there.

Dr. Joshua Eldridge: Okay and something that needed to get addressed outside. That’s kind of neat, that was a good part of that. Let’s move on. We did the Subjective, the Objective, and now we’re going to look at the Assessment. There’s a lot of confusion with the Assessment. I’ll be the first one to raise my hand on the confusion part. Assessment consists of three things. With the care, the relief, rehabilitative maintenance, the patient is improving, staying the same, getting worse, the diagnosis. Is this enough information to justify the legal assessment? Then the second part of that is what needs to be included in the assessment and what things should be left out?

Dr. Warren Jahn: Good question, the assessment component of the progress notes highlights the diagnoses derived from reviewing both the Subjective and Objective components and that is specific to this particular patient. The cause of the condition, any associated risk factors, comorbidity which we mentioned before, and that is two or more coexisting medical conditions or disease processes that are additional to an initial diagnosis. The hypertension, or the things that already had a torn hamstring muscle prior.

Dr. Joshua Eldridge: Okay, and you said two, explain that. You said there were more than two, two or more?

Dr. Warren Jahn: Comorbidities are two or more coexisting medical conditions.

Dr. Joshua Eldridge: Can you explain that just a touch more, the coexisting part?

Dr. Warren Jahn: Well, there is something else going on in the patient’s body that could be affecting how they heal. For instance, smoking, nicotine stores in the spine. If I have a low back condition that’s been going on and on and on, or has episodes, it comes back and forward, a big piece of that pie of back pain is going to be a nicotine wedge. Now, I got to get the patient off of nicotine if I can in order to be able to get them to heal better. That would be a big comorbidity if it’s a spinal related condition. In the Assessment, the current treatments that are in place are also included in this section. You want to make sure of that. You want to state the patient’s response to treatments, such as, “I have more flexibility in the neck, doc.”

Impediments to recovery include compliance, they’re doing it or not doing it and how they’re doing it correctly or not. Prognosis they think they’re going to get. Activities of daily living limitations and changes, if they’re going back and driving a truck and they still have back pain with leg pain going down after they drive one hour, and they’re driving for 10 hours, that’s not compliance. You’re going to have issues. Changes in short and long-term patient and clinical goals are part of this. On your initial exam, you’re going to lay out in the assessment portion what the diagnosis was and what you want to do with those diagnoses. Be able to walk across the floor with no pain in the foot in five days, something that’s short-term.

This is the most important component, this assessment for reimbursement and legally. This is the provider’s professional opinion in light of the Subjective and Objective components. It is the direct statement of the provider’s medical decision-making process. You might see that in your E&M codes. This is the medical decision-making process. Here’s what it is, it’s a cognitive process for selecting a course of action in the context of health or medical diagnosis and treatment. It’s all based on Subjective and Objective. Now you’re going to think about it. This is the section that most docs fail on because they’re not telling the story of how they got to this area, how they got diagnosis.

Dr. Joshua Eldridge: And in school, I think going through school and then coming out of school, the way I learned it, I think we put the assessment with something like before the plan or something of that nature, so that obviously fails.

Dr. Warren Jahn: Correct. The assessment component should explain the reasoning behind the decisions taken, the diagnosis in which you came up with and clarify and support the analytical thinking behind the problem-solving process. What am I thinking? Do I need imaging? Do I need laboratory studies? Do I need maybe to take them off of work? Those are the things and why. Their progress towards the stated goals are indicated short or long term, as well as any factors affecting it may require modification of the frequency, duration or intervention itself. This is where I might say, “Based on this, you’re getting better, so I’m gonna go to two visits in the next two weeks.” Adverse, as well as positive responses, should be documented here. The patient’s doing well, but when I tested to see how they were doing in a piriformis stretch, they had no clue what they were doing. That’s all in here. I got to re-educate, redo, observe, have somebody else do it, get a family member to watch and make sure they do it right, teach them how to do it exactly.

Dr. Joshua Eldridge: So then there’s that part if they’re not following through their exercise and that would justify other CPT codes and you could bill? Like, as far as I had to re-educate this person on this.

Dr. Warren Jahn: Yes, but that would go in your plan. The thinking of it and why you’re doing it goes in the Assessment.

Dr. Joshua Eldridge: That would justify your actions.

Dr. Warren Jahn: Correct. It will justify because here’s the thinking process, “He’s not doing it, so I got to do this, so now I got to spend extra time and educate him in the office, because at home it failed.”

Dr. Joshua Eldridge: One of the things I was thinking about, you talked about short and long-term goals. We didn’t get into those too much in the Subjective, but where do we put our short-term and long-term goals, and then what should they look like?

Dr. Warren Jahn: All in the assessment section. It really depends on what you want that patient to do. What I do is I go to aggravating factors which is part of your Subjective. “I can only run half a mile before I have back pain, can only bend forward for five minutes.” From that section, the aggravating factors, that will be my short and long-term goals based on what they cannot do. My job is to make them ready and to get them better in disability, rehab, back to the job, et cetera.

Dr. Joshua Eldridge: So you would take what they can’t do. Do you merge that in with maybe their personal goals, what they want to see happen, or does that not come into your thinking at all?

Dr. Warren Jahn: You could do that, it’s part of it, but that’s the least of what I usually do. I usually go, “What you can do, what you can’t do, let’s concentrate on those things.”

Dr. Joshua Eldridge: Do you list your short-term and long-term goals in your assessment?

Dr. Warren Jahn: Yes, you could do it 1, 2, 3, A, B, C, you could do that, or I like to just do a paragraph of it. Short terms would be a certain time period. Long term would be a longer time period, so maybe between re-exams, check the long term. The short terms would be that daily, that change an objective each time that they come in.

Dr. Joshua Eldridge: Okay, so practical things that you can see or that at least they can tell you.

Dr. Warren Jahn: Measure, smell, taste, feel, those things.

Dr. Joshua Eldridge: Okay, for your short-term goals.

Dr. Warren Jahn: Correct.

Dr. Joshua Eldridge: Right, and long-term goals are more of those things that they’re trying to do to be–

Dr. Warren Jahn: Go back to work, school, drive a cab, lift boxes, whatever it might be.

Dr. Joshua Eldridge: Sports guys back to their sport.

Dr. Warren Jahn: Absolutely, or start out in rehab to go back and forth, probably with like concussion protocols now, they take it in stages, that’s what these things are. What do I do next, how long do I wait, this, that, et cetera. This would be a good place also to talk about a little bit about guidelines. If you find guidelines for lower back pain, neck pain, whatever it might be, they’ll give you an algorithm. Then the algorithm, it’ll take you down. In the algorithm, usually on the bottom, it’ll give you the short terms and long-term goals of what you want. Do this this fast, do this long, I do this. If they can’t do this, then I have to go this way.

Dr. Joshua Eldridge: What are your go-to guidelines?

Dr. Warren Jahn: Anything that’s CCP GG. Those are the people that actually put it together for chiropractic, on the medical side, it includes everybody. Update is one and Cochrane Collaboration.

Dr. Joshua Eldridge: Those are ones we can link to too in the show notes, so people can get to.

Dr. Warren Jahn: That would be great because then it’s already there.

Dr. Joshua Eldridge: When an insurance company is coming after you on a review, are they going to be saying, “Hey, here’s the most recent guidelines from 2017 and you’re not anywhere near this.” Is that what they do, or is there some other way that they come after you, or how does that interact with what you’re doing?

Dr. Warren Jahn: It’s not the insurance company that does that. It’s usually the group that you belong to to get to the insurance company. There’s groups like Ash, certain brokers which you sign up to be in network. That network provider will tell you these are the things I need to see. These are the guidelines that I follow. Then from there, the insurance company pays them and then they pay you. That’s how that works, there’s an intermediary there, that will tell you things. Regular insurance company is hard to get to nowadays. In personal injury or bodily injury, there are general guidelines that you have to use, but usually, there’s no intermediary. It jumps right to the insurance company.

Dr. Joshua Eldridge: But you’re able to better justify your actions and what you’re doing if you base your treatment on the guidelines?

Dr. Warren Jahn: Initially, yes. You don’t have to follow all the guidelines, but that’s a great place to start. If you do that, you’re way better off than just winging it on your own.

Dr. Joshua Eldridge: That’s going to just give you that framework to build your practice from, or your treatment from.

Dr. Warren Jahn: Yes.

Dr. Joshua Eldridge: Tell me what needs to be in the plan, what are the components of a good plan and how should this drive your billing, and then finally, does each diagnosis code need an explanation for your plan?

Dr. Warren Jahn: The diagnosis code is included in the assessment portion. The thinking process and how you got to that diagnosis is in the Assessment process. Based on that diagnosis, short-term, and long-term goals, now we get into the Plan. What we’re doing, that visit that time. The future plans are in the Assessment, but what you actually do on the day is in the Plan section, because that’s the Plan, it’s not the future, it’s now, it’s what you do.

This is the one where most of the billing comes from your CPT codes of what you’re doing to the patient. This component outlines what you intend to do about the diagnosis from your assessment. This usually will only outline the plan for the diagnosis of the current visit. It should contain treatment information, referral to other providers or specialist, order labs, imaging studies or simply highlight a treatment plan that’s already in effect.

Basically what it comes down to is what you have done for or to the patient that day. It could be informed consent because you’re going to do another imaging study. It could be a report of findings, your second visit. It could be a report of findings from the initial visit. What worked and what didn’t work. “Well okay, we didn’t do that, so let’s change it to do this today.” What to work on for next time, is there any changes in the treatment plan that I got to make? Now I already thought about that in assessment, but now what am I going to do here is what I already have, what can I change now currently on this day, so that the patient can go on and we could test it out. You want to specify now all the things that you do.

You can’t just circle CMT, HMP, IST and think you’re going to get paid. You have to identify why, when, where that you did this. For instance, you want to put down what type of chiropractic manipulative therapy that was rendered. Was it flexion distraction, was it diversified, did you use a drop table, an activator? Then what areas were manipulated? “Well, I manipulated L4 and L5.” This comes into effect in case the patient claims that he was injured, let’s say at T12, but your notes say L4, L5, you’re golden because you never touched T12.

That’s important to put in there. It also tells you that you may change based on the area that’s involved. Maybe it’s not going to be L4, L5, maybe next time it’s going to be right SI joint that you manipulate. What soft tissues you manipulated. What specific type did you use? Did you do trigger points? Did you use Graston? Did you use a G5 or vibration machine? What did you do, how long you did it and to which part did you do it?

Dr. Joshua Eldridge: Now, how do you recommend people saying how long they did something? Should they say, “I did it for two minutes.”

Dr. Warren Jahn: Well, you can say that, but you’re not get reimbursed for that because reimbursement under Medicare guidelines is a minimum of 8 minutes in order to be done. It’s 8 minutes to 15 minutes is the initial ones. In regular insurance, they’re not supposed to follow Medicaid, Medicare but they do. It really should be 15 minutes, but most people start at 8 if you do anything. 8 for minimum and 15 as a maximum.

Dr. Joshua Eldridge: How do you actually put that though, in your Objective? If you’re listing your 15-minute time frame, would you just say 15 minutes or is there a better specific way of doing it?

Dr. Warren Jahn: I like doing times. I started at 9:10 and I went until 9:25 AM. That’s nobody can ever say anything about. If they put 15 minutes down and then you did 10 minutes over here and 30 minutes over here, 50 minutes here, and if they want to really see how your books are and how many areas that you have for a patient, they’re going to know that you’re not doing 45 minutes of that patient when you only got a slot for 10 or 12.

Time is much better. Some things you can do together. I can do a hot pack and electrical stim at the same time, put the electrical stim on and put the hot pack over, both of them would show the same time period. Soft tissue, let’s talk about that a little bit. Generically, you cannot do soft tissue to a spinal area that you’re also manipulating or adjusting, that’s the rule. It’s usually somewhere else. That’s why it’s very important to put down where you’re performing the soft tissue manipulation.

Dr. Joshua Eldridge: I saw a note today where a doctor, he did a four-region manipulation, did cervical, thoracic, lumbar and sacral adjustment. He also did soft tissue to the cervical, thoracic, lumbar spine. When I got into it a little bit more, I said, “That was a lot of soft tissue, what was going on?” He’s like, “Oh, I did the manipulation, they sent me over to this table. I laid on it and it did this like cool massage on my back.” He said it was amazing. He wasn’t actually applying the soft tissue manipulation to him, there was a, what do you call those, Spinalator?

Dr. Warren Jahn: Spinalator or intersegmental traction units. There’s a bunch of them out there. That’s a good example of a manipulation code, and then he probably tried to bill for 97140. Same spinal area, same area, can’t do it. Modalities, so there is all different kinds of modalities. There’s ultrasound, electrical stim in all different types. What you want to put down is what one you used, what the time period was that you provided, what the settings were. “Wow, doc, what do I have to put?” It was on a five or how many volts it was.

Every note or every portion of the note, if you can show progress is a plus to you. The great part about Plan, if I’m putting electrical stim on, and they’re at let’s say 40 volts one visit, the next visit, they can take it more up to 60, you just showed an increase of progress. It’s not just nitpicking, that’s important to do there. Make sure that’s the body part where you applied it. Where did you put the pads, right, left. Also for that, home instructions goes into modalities.

How to apply ice, how to apply heat, when, how long, where, those are the things that you want to do. Things that they can do on their own. Can they do stretches, strengthening exercises, but you have to put down sets, repetitions, how many times a day. If they’re doing weights, how much weight that you want.

Then how often they should come in for treatment. Every day for the first week, three times a week for four weeks, two times a week, whatever. Nobody can predict the number of visits. Basically years ago, that started with the practice management groups of saying, “Look, you just bought a table, the table costs so much. You gotta have these many visits in order to pay the table off.” That doesn’t jive anymore. Progress note to progress note, re-exam to re-exam is the way that things start and stop based on your notes.

Dr. Joshua Eldridge: We hope you enjoyed part one of this two-part series with Dr. Warren Jahn. On part two of this series, we discussed why doctors get caught up in audits, we summarize a SOAP note, we give a case example of how to do a SOAP note, and we give rules for completing your SOAP note. Don’t forget to pick up your SOAP note example as well as a SOAP note quick tip sheet available in our show notes at chiropracticepro.com/episode2. Keep doing great things in your office, and we look forward to seeing you for part two of documenting SOAP notes right here on the ChiroPractice Pro podcast.