Randomized SOAP Notes

I’ve by no means heard of a health care provider dropping an insurance coverage audit or going to jail as a result of his word had precisely the identical textual content, font, and so on to explain his affected person’s issues from one go to to the following.Right here is the place I consider that fable was born. When you use the logic above and you set your self within the place of an insurance coverage firm, you will notice that they should run a worthwhile enterprise. In the event that they paid each declare submitted by each chiropractor they’d lose some huge cash. (I nonetheless suppose they’d be worthwhile however that’s one other article.) From their perspective, they should set expectations for the affected person and physician for what shall be paid for and what won’t. To handle such expectations, they use medical necessity exams and depart it for the affected person to pay for no matter shouldn’t be medically needed.Within the medical world, if a therapy, drug, or remedy stops getting outcomes, then it can’t be medically needed, and the care should be stopped and/or modified. So, after they see notes that don’t change for a substantial time interval, they consider it as not needed, and they also deny its protection. That is the second when the “same note theory” comes into play. It’s not which you could’t say the affected person has a cervical vary of movement of 30 levels for six visits in a row. It means you’ll be able to’t say those self same phrases for too lengthy and anticipate another person to pay for the care. Sooner or later your “treatment” is seen as ineffective. Now if all you do is use totally different phrases or totally different order of phrases to say the identical factor, you might be nonetheless saying the identical factor and so your therapy stays medically pointless. It doesn’t matter what number of alternative ways you say it.Taking that within the unsuitable context, some documentation software program firms have banked on creating complete methods and advertising and marketing plans across the thought of randomizing textual content. The reality is there isn’t a “magic bullet” or methods, no “self randomizing note systems” that may assist you to receives a commission extra, or win appeals, or survive audits. Insurance coverage firms have specialists on board who’re in a position to uncover the identical message offered in a number of “randomized” variations. Making an attempt to beat the system will solely lead you to bother.Your documentation ought to inform a factual story concerning the affected person and reimbursement eligibility must be self-evident (particularly in case you need to defend your case). When you put the affected person first, you should have no bother with this.

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