January 1, 2021 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
While conducting a 2021 E&M Physician Training event for a client, like right in the middle of the session, I had an epiphany. Now maybe you have already had it- but I thought- WOW- we have made the full circle right back around to the SOAP note. When this thought hit me, I was in the thick of explaining the changes to history and exam for 2021 and the need to continue to use these contextually to help identify and convey appropriately the complexity of the patient encounter.
The SOAP note was developed years ago by Lawrence Weed, MD (a bit of trivia for you) to provide problem-oriented detail within the medical record. With the emergence of EMR and the development of the over-populated template driven by the desire to achieve a variance in the level of service by a mere “click” as opposed to complexity details, most templates have long since moved away from the SOAP note template. I can remember, some 17 years ago sitting in a physician breakroom of a client with my then department director of DoctorsManagement, Theresa, and saying to her- You know, I hate the SOAP note format because it places the emphasis on chief complaint and HPI but fails to remind the provider of the need to document the ROS and PFSH for the point value. I now find myself embracing that concept. If each and every carrier adapts and embraces the true value of the changes laid out by the AMA, then the SOAP note will once again rise as a poster child as one of the best templates to truly communicate problem-oriented patient documentation.
You see, within the SOAP note format, the “S” is used to identify the subjective requirements of the documentation. Let us take a step back for a minute and consider truly what subjective is to ensure adequate understanding of this concept, to enable each of you to best support your providers in this new-old form of documentation- remembering that the younger providers may not have familiarity with the technique. Subjective is a view based on or influenced by personal feelings, tastes, or opinion. It is a viewpoint of the presenting problem that cannot be forced upon or analyzed about the patient, as it is the communication of the patient’s own perception of their current medical issues. At times the subjective nature of the presenting problem may be over-indulged, if you will, by patients who have a lower tolerance for feeling unpleasant, while those with are more sustained threshold may relate as more conservative than the problem truly may be. Whichever the case, it is the job of the provider to abstract this subjective detail from the patient as a guide that outlines the objective approach of the provider.
Once again, the SOAP note comes through, conveying the change to exam documentation as well. Again, I refer to semantics. Within the SOAP note format, we refer to this portion of the documentation as Objective as opposed to Exam. So, is there REALLY a difference? Well, let the definitions speak for themselves. An exam can be defined as a detailed inspection or investigation conveying a checklist type of approach to the patient encounter. The definition of objective, rather is more complimentary to the 2021 approach to the exam portion of the encounter. Consider the definition- judgment or opinion in considering and representing facts, such a definition lending itself to an exam but one that is driven by the judgment and opinion of the provider as opposed to a listed requirement approach.
WOW! The definition variation between these 2 simple terms really helps to understand the transition of the 2021 AMA E&M Changes and we who education providers learn- we should STOP instructing providers to document “exams” and instead teach them to convey the “objective findings” within the details of the documentation of each encounter.
If in 2021 in the office/outpatient space, the exam is truly represented in terms that the extent required becomes based on clinical judgment of the presenting problem as opposed to the requirements of a fill-in-the-box audit grid- the SOAP note format, template, and thought approach is again, SPOT ON!
As this administrative relaxation has provided the necessary relief to reduce the click-oriented note, our providers should learn to embrace the problem-oriented encounter offered by the SOAP note. In order to do so, templates will need to be re-worked, re-written, and implemented. In theory, our providers could come back around from behind their laptop in patient rooms with a fresh new focus and awareness no longer distracted by clicking the right, or wrong, box on the EMR template. It used to be said that physicians, in particular of all of our provider types, were entrepreneurs gifted with the spirit of embodying a business based on the health and wellbeing of others. The reimbursement driven approach to the point-and-click medicine has squelched the entrepreneur right out of most and distracted our providers from our own well-being long enough.
The New Year’s Resolution of all providers should be problem-oriented driven documentation that accurately portrays ALL complexities with EACH patient’s health and well-being. The SOAP note represents an amazing way to accomplish this task, but of course not the only approach. Encourage your providers to make the necessary changes to their documentation flow as this new year begins.