How To Complete Pre-Med Requirements While Working A Full-Time Job Intelligent Electronic Medical Billing and SOAP Notes Software Requirements

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Intelligent Electronic Medical Billing and SOAP Notes Software Requirements

Physicians and therapists must produce medical records in ever greater volume and detail to ensure the best healthcare, achieve full and timely payment of medical claims, and protect the practice from post-payment audits and unfair litigation.

But the speed of the visit documentation conflicts with the accuracy and completeness of the documentation. For insurance companies, patient visit documentation must be accurate and complete. If the quality of the documentation is high, medical billing appeals related to unpaid claims are paid faster and at a higher rate. Otherwise, appeals are rejected and the case becomes vulnerable to post-payment checks, refunds and fines.

Insurance companies don’t care how long it takes to produce good documentation. But for the supplier, slow documentation impedes the profitability of the case and wastes valuable time. The physician must have completed the visit documentation before the patient leaves the office.

To ensure comprehensive note coverage, the healthcare industry has adopted a structured two-pronged approach. First, the clinician uses the SOAP note format, which reflects four key stages of patient care, starting with subjective observations, through objective symptoms, to diagnostic evaluation, and culminating with the treatment plan:

  1. SUBJECTIVE: The initial part of the SOAP note format consists of subjective observations. These are symptoms typically expressed verbally by the patient. They include patient descriptions of pain or discomfort, the presence of nausea or dizziness, or other descriptions of dysfunction.

  2. OBJECTIVE: The next part of the format includes actually measurable symptoms, seen, heard, touched, felt, or smelled. Included in the objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling, and diagnostic test results.

  3. ASSESSMENT: Evaluation is the diagnosis of the patient’s condition based on subjective observations and objective symptoms. In some cases the diagnosis may be a simple determination while in other cases it may include multiple possibilities of diagnosis.

  4. FLOOR: The last part of the SOAP note is the treatment plan, which may include laboratory and/or radiological tests prescribed for the patient, medications prescribed, treatments performed (e.g., minor surgery), patient referral (patient referral to a specialist), disposition (eg, home care, bed rest, short- and long-term disability, days off work, hospitalization), patient indications, and follow-up indications for the patient.

Next, each of the four key SOAP stages consists of templates that reflect multiple possibilities for each stage. The templates, organized in SOAP order, ensure comprehensive coverage and allow the clinician to simply select multiple on-screen selection boxes guided by a computer program.

The models have drawn dual criticism from both the provider and the payer. Vendors don’t appreciate the lack of built-in intelligence to reflect individual physician preferences for treating patients. Payers often suspect that the model-generated notes are of low quality and poorly reflect true patient status and treatment progress due to the model’s susceptibility to mechanical clicking and difficulty in interpretation.

The challenge is to combine the benefits of the model and detailed formats without their shortcomings to accurately describe a patient’s condition, ensure productive medical billing, prepare for regulatory scrutiny, and improve practice productivity. To overcome the perception of mechanically generated notes while saving the clinician typing time, some vendors have created specialized products that use randomized words for each pattern. These auto-generated notes include phrase structures, which closely resemble natural vocal patterns.

Flexibility and integration should be the key design features of SOAP Notes. In the initial section, for example, you create new patient records that grow organically with each visit or treatment. Built-in intelligence allows you to customize a document to your preferences and see the patient’s entire progress history in one screen. The system’s native integration with medical billing systems allows for automatic generation of claims, validation and sending to payers for payment.

SOAP notes shouldn’t simply emulate the paper record that every doctor has for every patient. They must use information technology to automate routine tasks and create a faster, easier, error-free process to increase firm profitability and reduce audit risk.

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