Coding insights: The SOAP note format and today’s EHRs

Q:With electronic health records, is it necessary to follow the traditional SOAP (subjective, objective, assessment, and plan) note format? Also, how should we handle and approach copying and pasting from note to note?

A: The answer here relates in part to the background of Federal Guidance for physician documentation and in part to the evolution of the EHR environment.

The first part of your question deals with format, and the SOAP note. Recognize that the rules that govern the documentation requirements for evaluation and management (E/M) coding and the auditing that follows are essentially unchanged from the 1995-1997 timeframe. Moreover, portions of these guidelines, the decision-making table or tables, have been around since the late 1980s. So the tool used to measure today’s note is at least 18 years old, with portions dating back more than 25 years.

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Enter today’s EHR, designed to meet today’s demands as well as the older documentation requirements. What you are seeing is a shift not in what providers do but in the way they record it.

In the linear version of the SOAP note--history, exam, and decision-making –the note ‘looks’ like the guidelines; they are in the same sequence. This has held true for decades, the information-gathering comes first, then the assessment or decision-making arising from that work.

And today’s EHR hospital admissions still follow that format, with the answer at the end. But I suspect what you are seeing is that in the follow-up notes, and maybe inpatient consults, the assessment and plan (A/P) portion comes first, at the top of the note, and then some of the supporting data follows.

Next: Note cloning

Physicians and other chart users have long gone straight to the A/P section when reading, reviewing, or auditing a note. That’s where you find the summary data-the answer, if you will-and depending on who you are, you’ll likely get the latest disposition or status of the patient.

The history and exam have always been more supportive in nature in a note-the under-pinnings of information that supports the A/P. Now, with the EHR, some providers have broken with tradition and put this information below. It’s likely more of a time-saving device than anything, because you don’t have to scroll through two or three pages of data to get to the answer.

Is this allowed from a regulatory perspective? Well, there is no guidance saying that the components of a given note must be in a particular place. And there is Medicare commentary suggesting that if the information is in the record and easily found and attributed then it is acceptable.

So for this component of your question the answer is that as long as all the components of the note are included, accurate, attributable, and meet all the other note requirements, then a change in sequence of the type described above is fine.

Note cloning

But your other comment, about copying from note to note, is likely much more concerning.

A portion of Medicare’s definition of medical record documentation is especially relevant here: The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates the ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time.

Next: What happens when notes don't change with successive days?

Set aside for the moment the obvious issues with copy and paste or cloning in the EHR. The definition above includes two references to time: “chronologically documents” and “monitor his/her health over time.” There is an aspect of copying or cloning that transcends EHR misuse and goes to quality and care and potential danger to the patient.

Often the newer version of hospital follow-up notes have the A/P, or running problem list, copied from day to day, and updated with new and relevant information. This makes sense. It’s a good use of technology–for the most part the list doesn’t change, and sometimes the status of the problems and even the treatment doesn’t change.

But what happens when the notes don’t change with the successive days? When it’s no longer truly ‘chronological’ or ‘monitors care over time’? We see a note on day three that has for problem # 2, ‘start medication X’. Then we see the same entry on day four, and day five, and maybe even day six.

The patient was not started on that med each of those days, so now we don’t really know when the patient started. Could another provider read the day five note, see this, and not realize that the patient has been receiving this drug for three days already?

Excessive copying without updating each element of the note or removing earlier entries can indeed lead to quality of care issues that go far beyond a documentation method or convention. Often we see several days of notes with compounded entries per problem that make it difficult to determine where a patient is in relation to a specific disease or problem.

Not long ago, two providers on the same service disagreed whether the first entry after a problem or the last was the most current! So each individual has his or her own assumptions as to what are increasingly becoming shared services.

Next: What appears to be may not be correct

Follow-up notes are prone to cloning in every component of the chart-the interval history, the exam and the A/P as described above. Every practice or group needs to develop an internal standard of documentation as to what constitutes an acceptable degree of copying. This is likely a regulatory hot button of the near future-cloning is too easy to do, and to do wrong.

Q:I was told that the ‘Episode of Care’ 7th character in ICD-10 doesn’t mean what it appears to mean. That ‘initial’ encounter doesn’t always mean the first encounter. Is that correct?

A: Yes, that’s about the size of it. The three values usually assigned to the 7th character for episode of care are ‘A’-Initial Encounter, ‘D’-Subsequent Encounter for injury with routine healing, and ‘S’-Sequela.

A common and non-coding meaning of the word ‘initial’ is first. And most folks would think there can only be one ‘first’ of something. But that is not what it means here.

The ICD-10 guidelines for coding and reporting of fractures directs the provider to use the ‘Initial Encounter’ character ‘while the patient is receiving active treatment for the fracture. Examples of active treatment are surgical treatment, emergency department encounter and evaluation and treatment by a new physician.’

So a couple of versions of ‘initial’ are found here. ‘While receiving active treatment’ can include the entire hospitalization, not just the first day. That is the longitudinal version.

‘Initial’ can also include the first encounter (or maybe more as above) with a provider other than the first provider to treat the problem. So yes, ICD-10 ‘initial’ means more than one thing, and not necessarily what it may appear to mean.

‘Subsequent’ is a bit more consistent with traditional meanings: ‘encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.’

If in doubt, look to your guidelines. Don’t rely on guesses.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a billing, coding, and compliance consulting firm. Send your billing and coding questions to: medec@advanstar.com.