Tag Archives: soap

PQRS reporting is simple

Now available & automated! You can easily and correctly report PQRS for Medicare (or other carriers). The necessary CPT G-codes have been added to your system along with logic to prompt for selecting the correct code when posting charges/visit info for  a patient that was designated for PQRS reporting. This will ensure that you insert the CPT G-codes as needed as well as record the correct ones based on previously used codes. Continue reading

Soap Notes: Point & Click Wizard Clinical Tips (part 2 of 2)

For an introduction & overview of the Point & Click Soap Wizard click here.

We have spoken to countless Chiropractors from clinics all over North America. One  recurring theme is that daily Soap Notes are a hassle. Some offices even store them in paper files. Ugh. Another theme – which is unspoken & not quite as universally accepted – is that Daily Soaps are not absolutely useful (when treating a few times weekly) but instead a necessary evil mandated by 3rd party payers. The theory goes that  insurers know the extra hassle of creating accurate, useful daily patient notes will slow reimbursement. Good thing for ChiroPulse365 or we’d have to consider calling in Scully & Mulder from retirement.  🙂

Luckily we can put all of that to rest because accurate daily patient notes are very simple to create in ChiroPulse365. Our clinical Team believes, as you do, that Daily Soap Notes benefit the patient, the doctor and your Chiropractic office.

Lets recap the four components of a Daily Soap Note:

  • Subjective portion is simply the patient explaining their chief complaints
  • Objective portion is the doctor clinically grading the patient (exams & more)
  • Assessment lets you, the doctor, quickly & accurately assess each chief complaint
  • Plan can be totally automated by using Careplan then making small tweaks as care progresses

Subjective – The Subjective portion is simply the patient’s grading their chief complaints. This allows you to document the patient’s problem(s) as they explain them to you the doctor.

Subjective: Location / Region
For the selected complaint, click on the location(s) and/or region to best explain the patient’s complaint. You can use any of the three boxes to better explain the chief complain as the patient explains it that day. For example the chief complaint of “neck pain” could be “bilateral” (location1) or “upper” (location1) “right” (location2).  The use of locations/regions are strictly optional & are not needed to make sensible notes.

Subjective: Location/Region of the selected complaint

Subjective: Location/Region of the selected complaint

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Quick Soap Notes with Point & Click Wizard

Creating clinically valid Soap Notes has never been easier than when using ChiroPulse365. One tool offered is the Point & Click Soap Wizard which allows you to create detailed & specific – yet clinically relevant – Soap Notes. This is touchscreen friendly and can allow the creation of a Soap Note without typing. It is even easier than it appears since once the initial Soap is created, the data collected is quickly viewed & used to start your next note for the patient’s next office visit. This allows continuity & validity of your clinical  documentation for all your patients.

The first thing to do for your patients is setup the Chief Complaints & Exams for the specific Claim (i.e. patient’s treatment episode). Remember you can have multiple simultaneous Claims running, each with thier own ICD-9 diagnosis, complaints, etc.  When you create a new Soap Note you will be asked to select which claim the note is for.

create a new soap note & select the claim it is for

create a new soap note & select the claim it is for

While in the SOAP Note Editor or Wizard you can quickly jump to  Claim Wizard Page-3 to view & change the complaints & exams! Do this effortlessly with the top menu or keyboard hotkey CTRL+F3. Note that the same keyboard shortcut is universally used in ChiroPulse365, in many windows such as Office notebook, Travelcard, Patient Homepage, Scheduler, Soap Notes, History, etc.

Use the menubar to open Claim Wizard page-3

Use the menubar in Soap Wizard to quickly open Claim Wizard page-3

The first goal is to establish what you want to clinically monitor while the patient is under your care for this treatment period (ie. claim). Complaint & Exam packages can be created for frequently used diagnostic scenarios. This will allow you to rapidly enter a preset package for “sciatica” or “headaches” with complaints & exams in your specified order.  These can be changed on-the-fly while doing Soaps using  add/insert, omit & remove;  or changed permanently (all soaps going forward) via Claim Wizard. Just remember it is best to setup your starting point in the Claim Wizard first.

In the example below we will change the primary complaint (selected in blue) in Claim Wizard. We then save the changes so that the appropriate complaints will appear when we create a new Soap Note for this Patient & claim.

Claim Wizard page-3 Complaints & Exams

Claim Wizard page-3 Complaints & Exams

The Point/Click Wizard has started in the picture below, ready to create a new Soap Note.  In the Wizard you work from top to bottom, left to right & remember that almost everything is “clickable” or selectable. You can see in this example three (3) Chief Complaints are used for Carmella but the “shoulder-arm…” complaint is Omitted for this note meaning we will skip that complaint for today’s note. Use omit to skip a complaint or exam while keeping it in the Claim Wizard for use later, such as if an exacerbation occurs. You can delete the complaint so it will not appear in the next new Soap note.

Use the SOAP tabs to navigate between components or simply use Next/F3 to go from finding to finding (ie.  location… description… better… aggravated) to quickly loop through & visually create your Soap Note. The keyboard shortcuts allow you to navigate a Soap without grabbing for the mouse. If you are using the mouse however, you can click on any blue text link to jump to that data panel.

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