Today’s guest is Dr. Warren Jahn. 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 in his role as a forensic diplomate. We’ve put together an example SOAP note for you as well as a SOAP note quick tip sheet available in our show notes at chiropracticepro.com/episode3. Now here’s our special guest, Dr. Warren Jahn.
I jotted down a question that I had because I hear a lot about them standing on their own. How do treatment plans play into this whole thing, and is it important to have one on its own, or can you have it just included in your note? If you had a note, an EMR that could complete its own, or if you had paper charts and you could do your own type of treatment plan that you could refer back to, can you do that?
Dr. Warren Jahn: Yes. There are some EMRs or just paperwork that will have a treatment plan sheet and they’ll fill that out. The problem is, you fill it out on the first visit and you never see it again. If it’s in the EMR, you can always, in the note in the plan, refer back to the treatment plan. Then you can just hit a button, boom, there it is. If you’re not including it in there, then it doesn’t mean anything.
Most treatment plans are at the beck and call of those brokers that act as intermediaries between insurance companies, they’re the ones that want to see a treatment plan. Unless it’s specifically asked for, you really don’t need one. The plan, the assessment where you’re thinking about what I need to do and the plan actually identifies what your treatment plan is. I think physical therapists call it Plan of Care, or POC.
Dr. Joshua Eldridge: We’ve kind of gotten through Subjective, Objective, Assessment and Plan. Bring this all together, give me a summary of it all and how it all works.
Dr. Warren Jahn: All right. Let me give you a few little things that maybe you can remember this, because it’s at the end of a conversation. SOAP formatted notes are a simple, yet comprehensive technique used by all health providers by taking contemporaneous notes of your patient’s encounters, you will find it’s much easier to organize complex problems into simpler parts. Doing so means that caring for this patient is easily tracked and conditions are managed or resolved.
SOAP formatted notes also help medical professionals identify obstacles in the patient’s care and provides concrete evidence of progress. Here’s a formula, I don’t know if you remember your geometry and algebra. S plus O equals A, which yields P. What that is, Subjective plus the Objective equals your Assessment. Based on the Assessment, that leads to your Plan, very simple. If you can remember that, it’ll be great. Your Subjective findings plus your Objective observations equal your Assessment which leads to your Plan, simple, easy to understand.
There’s always some rules for charting. We covered this, but a little highlight. Chart in chronological order, write objectively, don’t put in biases, opinions, judgments. Years ago, we were taught the patient’s don’t show up for visits, you might want to grade your patients. A) They show up all the time, do everything. B) Well, they show up once in a while. C) They never show up. You never want to put that in the note. You just treat the patient and no bias, and no opinion. Don’t write generalizations. In other words, don’t say good, fair, usual, better, improving, that’s not good.
You have to put it out and compare one visit to the other. Here’s another one. Don’t double chart. All right, so very commonly, people have health insurance, so they have one chart. They have personal injury, they have another chart. They have work comp, they have another chart or a record, never do that. That gives the impression right off the bat, if we find out that there’s different charts or EMR records like that, we’re thinking what are you hiding?
Dr. Joshua Eldridge: You mean with each patient or between patients, which one?
Dr. Warren Jahn: One patient, they have different things that you’re doing. You’re billing for bodily injury to auto insurance. You’re billing the health insurance to health insurance, and you’re billing workers comp to workers comp. You’re still seeing the same patient on the same visit, only you have different notes and you have different billing systems, don’t ever, ever do it. You never heard of that, did you?
Dr. Joshua Eldridge: No, that’s kind of sketchy.
Dr. Warren Jahn: It is bad. Right off the bat, everything goes down. The way to do that is to outline problem number one, problem number two, problem number three in the subject. Number one is your workers comp, number two is your health, and number three is your auto. Everything is all in there identified. As you go down the objective, should be the same for all of it. Then when you get into the assessment, okay based on number one problem,
I’m going to do this. Number two problem, I’m going to do this. That’s where the problem list came from. Most of these, problem orientated. There’s a problem list over here that you write one, two, three, four. As things get better, like you control the hypertension because the Family Practice doc gave them some medication, that would be less of a comorbidity. It’s important to identify where you’re going and to keep it all together for the benefit of the patient.
Dr. Joshua Eldridge: When we’re talking about the Subjective part and even the Objective, should you have a separate note, and not a separate note like a different SOAP note, but a separate portion of that SOAP note for each complaint that they have.
Dr. Warren Jahn: Correct, so it’s number one, number, two number three.
Dr. Joshua Eldridge: And in the subjective, what about in the objective?
Dr. Warren Jahn: Same thing. Basically, it should be very similar because it’s spinal related unless you’re doing extremities, then you would have one or two in there. But the diagnoses are going to be different for problem one, problem two, problem three. Then the Plan obviously is going to be a little different. That’s how you do it. You just keep it in one note, one place, one time. The easy part is you discharge them from the one injury, and now you started out as new. Unless you think that that exacerbated the condition from let’s say the bump in the parking lot in the car. It all depends.
You are the doctor, you’re the one who has to lay it out, but it has to tell a story. Why I did this, why there’s an increase in care now, because they did this and that. The last thing, and I’m sure your note does that, you have to sign the end of the note with your first name, last name and professional title. You have to identify who’s performing what. If you have a physical therapist or some other professional in your office and they do a certain portion of things, their names should be underneath that section.
Final thing, this is a good thing to remember. To help gauge if you’ve written a good SOAP formatted note, apply the dead provider rule. If you get run over by a truck tomorrow, could another doctor walking in with no idea of what’s going on understand what’s wrong with the patient, where they are in their progress and so on. That’s a measure of a good documentation.
Dr. Joshua Eldridge: Can we do a quick kind of exercise? I’m your patient. Do a history, make-believe a little physical exam and then tell me what you would write down.
Dr. Warren Jahn: Okay, let’s say you come in, I’ve already looked at your medical records. Imaging if I have it, et cetera. You’re going to come in, okay, what seems to be the problem today?
Dr. Joshua Eldridge: I got low back pain.
Dr. Warren Jahn: All right. Stand up, turn around, show me where your pain is.
Dr. Joshua Eldridge: All right, it’s right down left, SI joint region.
Dr. Warren Jahn: How do you know SI joint?
Dr. Joshua Eldridge: I went to a chiropractor school, but I failed.
Dr. Warren Jahn: Okay, basically they will point to a certain area of the back. My note would be, “This is a 39-year-old male with a chief complaint of pain across the lower back region. (points to the right Sacroiliac joint)” What’s your pain level today?
Dr. Joshua Eldridge: 2.
Dr. Warren Jahn: Okay, 2/10. All right, so just by asking that, seeing where it is, that’s my first part of the note. I’m gonna say, “Does it go anywhere, does anything make it worse? What makes it better?” Those types of things in there.
Dr. Joshua Eldridge: Yeah, it goes into my left glute region. I hate to run, but it really, really flares it up when I run. Definitely stretching and doing some extra movement helps to relieve it.
Dr. Warren Jahn: Okay, so those are the things that I would write down. Just say it exactly as you said, but I would put it under, “What aggravates it, what makes it feel better.” Because I’ll ask them that. “Okay, how long can you sit for?”
Dr. Joshua Eldridge: 20 minutes.
Dr. Warren Jahn: How long can you drive for without squirming?
Dr. Joshua Eldridge: 15.
Dr. Warren Jahn: If you’re standing in a movie theater line or a grocery store, how long does it take for you to lean on the cart?
Dr. Joshua Eldridge: Almost right away.
Dr. Warren Jahn: Okay, all those things that I just asked, I would be able to get information that goes in the Subjective. That’s the part that I can use now for the short and long-term goals because I want them to sit longer, drive better, be able to go around in the grocery store. Then I’ll ask them, “All right, what are you doing when you have the pain to make it feel better?”
Dr. Joshua Eldridge: I’m popping my own back.
Dr. Warren Jahn: Okay, what else?
Dr. Joshua Eldridge: I like the foam roll.
Dr. Warren Jahn: Okay, how about a hot shower?
Dr. Joshua Eldridge: Hot shower feels great. Bath with Epsom salt.
Dr. Warren Jahn: Great, how about ice, heat?
Dr. Joshua Eldridge: Yeah, the heat mostly.
Dr. Warren Jahn: Okay, what kind of heat do you put on?
Dr. Joshua Eldridge: I like to use one of those hot packs from Walmart.
Dr. Warren Jahn: Okay, not a heating pad plugged into the wall and you sleep on it?
Dr. Joshua Eldridge: No, unless I’m taking the plug-in one, I put it in the bath with me sometimes, is that okay?
Dr. Warren Jahn: No, that’s not. Foam roller, I’ll ask. Lacrosse ball, I’ll ask. Anybody walk on your back?
Dr. Joshua Eldridge: My kids.
Dr. Warren Jahn: Okay, and you pop your back. Here I say, how many times in an hour or in a day do you pop your back?
Dr. Joshua Eldridge: Probably 20 times on a day.
Dr. Warren Jahn: Okay, what’s the most comfortable position for you to sleep in?
Dr. Joshua Eldridge: I have to be on my right side with a pillow between my legs.
Dr. Warren Jahn: Okay, do you ever wake up on your stomach?
Dr. Joshua Eldridge: Occasionally. I don’t like it though, I’m in a lot of pain if I wake up on my stomach.
Dr. Warren Jahn: It makes it worse. Okay, so those are the things now of what they do that’s maybe making it worse, aggravating it, or whatever. I would tell them things like, “You’re not able to sleep on your stomach. You have to totally stop popping your back, or just stop all stretching, because it looks like you’re overstretching. No foam roller, no lacrosse ball.”
Things that they think are making it better or making it worse. I’m taking some triggers out and then this is part of my Plan now. As I’m thinking, this is what I’m writing down. “Discontinue boom-boom-boom-boom-boom.” or “Doc, it only hurts when I arch my back when I go back over a chair and I get it to pop, or I twist over like this.” “Single leg throw overs, I want you to stop all those things.”
Dr. Joshua Eldridge: So we’re going to put those in the Assessment part, or actually in the Plan? What we’re telling them to stop doing?
Dr. Warren Jahn: That’s in the Subjective. Finding out is in the Subjective. I then take those things and when I get to the Assessment, that’s when I start determining what they have to not do. The Plan is what I do that day to them.
Dr. Joshua Eldridge: Okay, so you might move down to the Plan and do one of the exercise, or one of the things and tell them to stop doing it, or that would just be counseling?
Dr. Warren Jahn: No, that would be counseling. All that’s counseling on what to do and not to do. Remember, Subjective is what the patient tells you, all the story. Whatever comes from the patient is subjective. The objective now, I’m testing them to see what I find out and what I think I can come up with for a diagnosis.
Then the assessment is the diagnosis itself written in there, and what I’m thinking about, how I arrived there. Do I need X-rays, do I need this, do I need that? What things to discontinue, what things to increase, and then the plan is actually what I do that day.
Dr. Joshua Eldridge: For me, with that history, which isn’t too far off, but I don’t really like popping my own back. I don’t use a heating pad in the bathtub, but what kind of things would you then move on in the objective to kind of look at?
Dr. Warren Jahn: I do the normal inspection, palpation, range of motion, neurological orthopedic test and any kind of special tests that are in there.
Dr. Joshua Eldridge: In the next podcast that we have, we get deep into the exam, so that would be good there. Let’s just say my straight leg raised on the left was limited and I have shooting pain down my leg. I have a limited range of motion, neurologically, maybe I’m weak in certain areas. Can you put those together in the assessment? How would you then put that together?
Dr. Warren Jahn: You did it perfectly. Whatever you just said, that’s the data, you just write it down, that’s perfect. Write it down in the objective. Doesn’t matter what order it’s in, as long as you put it in there.
Dr. Joshua Eldridge: All right and then combine them with the subjective, and not objective. Tell me your S plus O equals A.
Dr. Warren Jahn: S plus O now equals A. Based on those two things, they told you in school that 90% of your diagnosis comes from the subjective, from what the patient tells you. You already knew, that’s why you did the objective. You’re doing the test to verify what you think it is. Now you go to the subjective. You got a component of radiculopathy. I don’t know what it’s caused by, I don’t know if you had surgery, not surgery, those types of things.
Radiculopathy would be the number one thing that I would put down there. Now that I put a neurological, and by the way, diagnosis go in hierarchy. The worst one first, neurological in this case would be the one that I’m more worried about, so that would be number one. Then under that, you would put whatever low back facet syndrome, degenerative disc disease, whatever else you find on imaging, et cetera. And then you would go down if there was anything else. There then, I would put comorbidities. Whatever your comorbidities are, that would go under that, and then I would get into talking about order this, send to physical therapy. What do I do now?
Dr. Joshua Eldridge: Can comorbidity be that eight strokes over my handicap, like on yesterday’s?
Dr. Warren Jahn: No, that comorbidity is playing golf, that’s stuff that you get.
Dr. Joshua Eldridge: We’ve taken all that, we put it in there in the assessment, and then for plan, how would you layout that? Are you ready to move on to the plan then in our example?
Dr. Warren Jahn: Yeah, once I know what I’m going to do now, I don’t have to treat them that day. There might be something I have to order, like an MRI or something. I got to stop. If I think there’s some other tests or something that has to be done there, I stop, I don’t do anything. Now, I might tell them to do some home things. Maybe how to sit, maybe put ice on it. Those things that no matter what the MRI comes back with, I can have them start to do.
Dr. Joshua Eldridge: Okay. Let’s say just as a sidebar, you tell me, “Here’s an order for an MRI, your appointments tomorrow at 8:00.” I come back at noon tomorrow and I say, “Dr. J., I slept in this morning, the coffee shop was having a special so I went there instead of the MRI, but I’m ready for my first treatment.”
Dr. Warren Jahn: When we can’t do it, the piece of the information I need, you didn’t go to, we have to reschedule you. Reschedule MRI first, that’s the important thing. Until I get that information, I can’t see you.
Dr. Joshua Eldridge: Why not?
Dr. Warren Jahn: Because I’ve already made that medical decision-making process that I need a test. If I did it then, there was a reason why I did it then, and there’s no reason to change that. I could tell that the condition of the patient’s still the same. Hopefully that I took a little history and I did an objective exam on them, and then they tell me why they didn’t go. Exam stops, reorder it, here we go.
Dr. Joshua Eldridge: Yeah, but I’m going to pay you double today. If you just give me that that pop, I need that pop.
Dr. Warren Jahn: No thank you, no chicken stew.
Dr. Joshua Eldridge: What happens if you do go ahead and do that, and I deteriorate? How does that look as far as the legal aspect of that?
Dr. Warren Jahn: That’s the problem, you made a decision and even though they didn’t do or follow through, you treated the patient anyway. Now, they go down or something happens, or let’s say, the wife now after your visit, they go home and have to take him to the emergency room because now he has no feeling in his leg. That’s your responsibility, you’re the one who did it. You will be probably told that you did something negligent, the negligent was you changed your mind and you didn’t get the test that you thought you had to have.
Dr. Joshua Eldridge: Okay, all right. That’s a super important part of this.
Dr. Warren Jahn: Very important. Don’t ever recommend something and to give in for whatever the patient may have. If you’re going to treat them, treat them. But you’re going to have to take the liability that goes with it and not worry later on that you have to do something.
Dr. Joshua Eldridge: Then plan, we’re moving this over to plan from the assessment. How do you kind of finish it all up?
Dr. Warren Jahn: The planning in this case, if they didn’t have the MRI, do not treat the patient until MRI results are reviewed and gone over with the patient. You put it in there what the plan is. You already did that also in the assessment portion saying, “Look patient didn’t go. I’m redoing the appointment at the MRI, not scheduling them until they get it.” And then in the plan, this is what you do. Sometimes, it’s a repetitive thing, but thinking of what I told you, the assessment is where you’re thinking the logic behind what you’re doing in every performance.
Dr. Joshua Eldridge: This is kind of the last little thing. Tell us about the story aspect of this.
Dr. Warren Jahn: Well, that’s the story. The story is if I come in and I have to audit your file, I start at the diagnosis. I start to diagnosis, okay that’s the diagnosis that he came up with. Let’s say, intervertebral disc syndrome. Does he have leg pain, back pain? Can he walk, can he toe walk, can he do those things? Now, I go to objective. I have to look for those things. Then I go to subjective. Okay, what led him to believe that he had to do those tests and come up with that diagnosis? Now the subjective is there. You start as a provider, subjective, objective, assessment, plan. As an auditor, they go the opposite way. Diagnosis, objective, subjective.
Dr. Joshua Eldridge: I don’t think most people know that.
Dr. Warren Jahn: No, they don’t. They have no idea.
Dr. Joshua Eldridge: Especially a young doc coming out of school, what’s the advice you’d give to them? How many notes have you seen? A million?
Dr. Warren Jahn: Tens of thousands.
Dr. Joshua Eldridge: Yeah, lots. What’s your advice to those young guys that are just getting out?
Dr. Warren Jahn: Take the time to do the note, come up with a plan, a procedure. Use the EHR that you have in front of you. If there’s an open spot and there’s something important, make sure you put it in. Don’t just check off things. I’ve seen EHRs where they’ll have little reminders. If there’s something about leg pain, and you did reflexes, sometimes the ER comes up the next visit, don’t forget to check reflex. In your mind, you have to do that. Whatever your most important things in it, in the case we just talked about that leg pain, that’s the important thing. Neurology is what you have to do. Check the surface for tactile sense, reflexes, strength.
Dr. Joshua Eldridge: If you see a deficiency in one of those, you need to be doing those each time?
Dr. Warren Jahn: Yes, until they improve because that’s what you’re doing. You’re trying to get that person to improve. Here’s a rule of thumb, if I have any radicular pain in arm or leg, if a patient responds, the pain will start to two things, get less in intensity and start to creep up the extremity. Come out of the lower part, then come up and then come up eventually. It always has back and neck pain, no matter what, even though they think that that’s the only thing they feel.
It’s there, it’s just that the brain only can take so many impulses in there, so it picks out the one that’s really throwing the impulse out. Those are the two things you have. Now, if I don’t get improvement in three to five visits, something’s wrong. Either change the diagnosis, get some imaging, something’s not right. As you get more experienced, that’s what you’re going to find out. As a rule of thumb, check it, do it, write it down, do it now.
Dr. Joshua Eldridge: As an auditor and seeing these notes, what are the biggest things that you’ve seen over the years that have really nailed docs?
Dr. Warren Jahn: Lack of notes, not having what you want, what we just talked about for the last hour or so. Got to write it down. It’s not written, it wasn’t done. That’s the big deal. You got to take your time and write the note. That’s why my thing is if the patient’s sitting right there, I’m writing a note as I’m going.
If it’s an EHR, I’m going through and I’m doing this. I like voice recognition. I like dictating, it’s quicker. I type 16 words a minute. But I can dictate over a hundred. That’s how I get it in there. As they’re sitting there, I’m getting the notes almost done until the end, and then I got to decide what I’m going to do.
Dr. Joshua Eldridge: Just as a quick tip on that, Apple’s voice-to-text is amazing when it comes to documentation. It goes really quick, it’s better than Dragon, yeah, way better. Apple would go back, let’s say you say a sentence. It’ll take it in context, and then go back and fix it to what you actually said, whereas Dragon has no clue what you actually say.
Dr. Warren Jahn: Right, you have to repeat it.
Dr. Joshua Eldridge: Yeah, so good. That’s a great way to get it down exactly the way you want it. Good, do your notes, have better success.
Dr. Warren Jahn: That’s the only way you’re going to protect yourself. Look, you went to school, you got all these loans and you owe all this money. You want to continue, right? Protect yourself legally and reimbursably, so you get reimbursed for your family’s sake.
Dr. Joshua Eldridge: We take a break right here to get back into some of the rules of completing SOAP notes. This is a bit more dry than our other conversations, but listen close because there’s a lot of depth to this section, and it will help you fine-tune your documentation.
Dr. Warren Jahn: The SOAP note formats are now commonly found in electronic medical records or EMRs. The purpose of the SOAP note format was to standardize medical evaluation entries made into the clinical record to help facilitate, improve communication among all involved in caring with the patient and to display the assessment problems and plans in an organized format.
It’s a great way to communicate with other healthcare professionals to encourage referrals. Insurance companies accept it as proof of medical necessity and reasonable care, and it provides evidence for attorneys as proof of significant injury.
Dr. Joshua Eldridge: That’s where I think a lot of people get in trouble is they don’t provide enough information to communicate with others, or they don’t know how to provide that communication.
Dr. Warren Jahn: That’s probably a combination of all those, but it seems like the progress note is the last focus in the whole documentation or the whole treatment regime and it should really be the major one.
Dr. Joshua Eldridge: For me, I know coming out of school and even through my first little bit of practice, we were taught SOAP note, and I’m still learning. You’re teaching me a lot. I’m still learning how to make them flow. I think that’s one of the things, the communication part of it. You talk about the story a lot, and hopefully, we’ll get into that some. But yeah, just that whole story seems to be in communication, seems to be an issue.
Dr. Warren Jahn: Well, reimbursement is the main thing, and protections legally is the other. To me, those are the most important, and then the storytelling comes after you do some of these things.
Dr. Joshua Eldridge: Right and get a little bit better at it, Jedi Master style. When do we do progress notes, and using that SOAP format that you talked about?
Dr. Warren Jahn: On every subsequent patient visit or encounter. It means every time that you see that patient, there should be a progress note formulated. Documenting your patient’s visits, utilizing the SOAP format will help create a better patient note and more comprehensive medical records. If you take contemporaneous notes of your patient’s complaints, your observations, treatment being performed, and plan for future treatments, you’ll be focusing on finding a solution much easier to the patient’s complaint or problem.
By following the SOAP note-taking format, you’ll create a standard for organizing and documenting all of your patient’s information during your visits. Taking contemporary notes of your visit with the patient will save you time from trying to recreate your notes later in the day, week, a month, and that’s the issue.
Dr. Joshua Eldridge: Right, are there any quick tip just at the beginning here, how do you make sure that it’s, you call it contemporary, right? Make sure you do it right then, how are some of the things that you do that?
Dr. Warren Jahn: Well, you’re just going to have to take the time. Some people have other folks come in and record, others have a dictation machine or a recorder where they write it down to give them memory of what’s going on, but unless you do it contemporaneously, you’re never going to get right, because you’re going to forget.
Dr. Joshua Eldridge: Especially what the patient says which we’ll get into that soon, and you talked a lot about that. What’s a habit as a new doctor, existing doctor trying to be the best at their trade to develop as he or she gets out of school and starts formulating progress and SOAP notes? What kind of habits should they start forming?
Dr. Warren Jahn: Hopefully in your internship is that you are going to school and seeing patients and your student clinics, and then your graduating clinics that you get out, you actually did these types of things. Let me suggest some important concepts that you should be acutely aware of. First of all, listen. You got to remember to listen to your patient and let their responses guide your interview. You got to be ready to recognize from your patient’s communication any gaps that they leave which you should endeavor to fill by asking appropriate questions.
Make use of every possible opportunity to use your non-verbal expressions to show your understanding and concern for the patient. Sidebar, we are always top in all the surveys that we are the best in listening to our patients, yet, we still have not the best progress notes. The questions that you ask should be open-ended in that they require more than a yes or no response. This allows the patient to describe their circumstances in their own words. Closed-ended questions are questions that you ask the patient that require a yes or no answer.
Close-ended questions do not get the whole story, and you need to ask a lot more question. Here’s an example, “Are you hurting today?” Open-ended questions are questions that you ask the patient that require more than a yes or no. Open-ended questions are more valuable and more useful in determining what the patient wants.
Here’s an example. “Where do you feel the pain right now? Where does the pain start?” I might say that and ask questions, and let the patient ramble a little bit. If you have a set routine on which you ask certain questions and get the right information, you can just say to the patient, “Let me ask you some of these questions.” If there’s any gaps or things that are missing, let me fill it in and the time period will be a lot better, and you’ll get a lot more information.
Dr. Joshua Eldridge: Can you give an example of what you’re referring to on that point?
Dr. Warren Jahn: “Doc, it only hurts when I do squats, or when I run.” “Okay, we’ll get to that in a little bit. What I need to know is when did it start, where was it, does it travel anywhere?” Those are the things that I need to know so I’m able to get the progress note in there, so I can document from visit to visit, encounter to encounter if there’s any change. Another important concept is organize your thoughts. Though you want to take notes during your encounter with your patient, taking a few minutes to think about what you want to write before starting your progress notes will avoid wordiness. Before you write your SOAP notes, organize your thoughts. For example, you do not need to write everything in the same order the patient reported it.
Take a few minutes and think about what you need to include and in what order you may want to write it out. That’ll help you. If you’ve got it written down, or on a recorder, jot it down and then organize it. In the note, you want to then summarize the visit. It’s generally not required, but highly recommended to quote a patient on their symptoms especially if they use very specific words that may help with their treatment. If a patient goes on a tangent and gives extra detail about their symptoms, it’s appropriate to get back on track and omit any extra details that don’t help with their treatment out from your notes.
Any information that the patient gives you that doesn’t help with the general health information or well-being information should be left out. Personal and confidential information should never be included in the contemporaneous notes of your visit with the patient.
If they say, “Doc, I feel as if something was exploding behind my eye.” That would be something for me to quote because that’s important information. Another important subject, avoid excessive acronyms and abbreviations. On travel cards which we don’t recommend, but a lot of people have these little abbreviations.
Dr. Joshua Eldridge: What do you recommend them, just real quick?
Dr. Warren Jahn: Because they’re only circle or check off, and there’s no room on those things ever to fill in all the gaps that you really need to document their progress. It is not good enough to put better, improving, some words like that.
Dr. Joshua Eldridge: I had a buddy who I filled in for, and he had travel cards. I bet you when he got back to the office, he was pretty upset because I would have notes written all up and down that for a travel card and recommendations to go to orthopedic surgeons. I made room.
Dr. Warren Jahn: That’s a problem, there is hardly any room. That’s what ends up in your note, so it looks like the same thing over and over and over. When you create your SOAP note format, it’s important to remember that other medical or legal professionals may need your progress notes to treat other conditions the patient may have or will have.
If you use an acronym or abbreviation, be sure to use one that is officially recognized and not one that is just made up by yourself or staff. If you know that other medical professionals will likely understand your abbreviations, it becomes professional and prudent to use it instead of writing out the whole word or wasting time.
Dr. Joshua Eldridge: Is there a good place to go to get that information? Where’s a good site or organization that has a list of those?
Dr. Warren Jahn: That’s a good question. It depends if you’re in an interdisciplinary clinic or a hospital or MUA facility, they’ll have their own standardization. Your insurance companies that you deal with, they may have some. But usually Medical Associations, probably even the American Chiropractic Association probably has a listing of those that are there. In some hospital settings, they’ll actually tell you what abbreviations not to use because they become confusing, because they seem to be multiple things for a certain letter or two.
Dr. Joshua Eldridge: And whenever you have a Joint Commission survey, you always get the email from the hospital administrator telling you, “Hey, stop using these abbreviations.”
Dr. Warren Jahn: That’s correct. All right, so other important topics, about two more or so, three more. Late entries, progress notes must clearly be identified as late entries. Documenting activities out of chronological order may suggest that the record is not accurate. This suggestion may be tampered by appropriately recording late entry.
Never leave blank lines for someone else to insert notes, kind of like you did on a travel card. If there are blanks in your record, you must put a single line through the area to ensure yourself or anyone reading the record that there was no opportunity to alter the original record. Insert a text or text that extends beyond the recognized writing or reading or recording area may also suggest that notations were made as an afterthought, or to cover up activities.
Dr. Joshua Eldridge: That’s what you’re talking about on written, when you’re actually using pen and paper.
Dr. Warren Jahn: Correct, but putting them in chronological order still applies to electronic medical records. You can’t just refer back. Just put it in, say, “This refers back to the note on January 30th, 2017.” so that they correlate.
Dr. Joshua Eldridge: Is there a late entry statement?
Dr. Warren Jahn: What you can do, “Patient was initially evaluated on, late entry was made on–” and go from there.
Dr. Joshua Eldridge: Right, do you ever give an excuse?
Dr. Warren Jahn: Let’s say it’s the end of the day and the kids got to go to a softball game. I can’t finish up the note, so I got to come back the next morning. Just office hours ended and I came back the next. Corrections, now corrections can be made in the electronic medical record or in the written record. We’ll talk about electronic medical records.
Nowadays, you will always see the original note usually on the bottom of your note that’s there, maybe either grayed out or smaller to the record that you just changed or made changes to. You never want to erase, you never want to obliterate when you’re doing those things. In electronic medical records, different in written records, you have to put a line through it. You have to initial it, you have to date it, and then put the correction underneath or at least don’t white it out, that’s the other thing. This is important in the medical-legal realm.
If a med mal case, God forbid ever comes against you, they’re going to look to see what you really said, what you thought that may have changed, and then your credibility is shot and then your case starts out at very low ebb or area. Last thing, if it’s not written, it didn’t happen. This is important. Even negative findings should be in your medical records. Those are important to worry about. Again, if it’s not written, it did not happen.
Dr. Joshua Eldridge: Are you reporting everything you do to be in there? Is there anything that should ever be, you already said leave out if you’re talking about the dog, leave that out unless it has to do with your pain. But if there’s anything else you do, should that always be included?
Dr. Warren Jahn: You include positives and negatives. You include things that are really pertinent to the information that you need, everything else, you don’t have to put in.
Dr. Joshua Eldridge: All right, Warren, thanks for joining us. That was awesome. Hopefully, we’ll have you back and we can talk about more of this someday.
Dr. Warren Jahn: Okay.
Dr. Joshua Eldridge: We hope you’ve enjoyed part two of this series with Dr. Warren Jahn. Don’t forget to download your SOAP note example as well as the SOAP note quick tip sheet available in our show notes at chiropracticepro.com/episode3. Have a great day and we’ll see you next time right here on the ChiroPractice Pro podcast.