SOAP Notes and Coding

What are the risks of over-coding?

• auditing and refunds for overcharging

• decrease in trust in field

• disciplinary consequence

What are the risks of under-coding?

• failure to get credit/reimbursement

• skewed data (giving patient a product and not billing for it)

What does the S in Soap Notes stand for?

Subjective

everything the patient reports

What does O in SOAP notes stand for?

Objective

• everything the clinician see/does

What does A in SOAP Notes stand for?

Assessment

• based on S and O, this is what you plan on providing for the patient

What does P in SOAP Notes stand for?

Plan

• was the problem solved?

• when is the patient coming back

• final notes given to patient (cleaning instruction, wear schedule, etc…)

What is malfeasance?

execution of an unlawful or improper act

What is misfeasance?

improper performance of an act

What is nonfeasance?

failure to act when there is a duty to act

What is criminal negligence?

reckless disregard for the safety of an individual

What is malpractice?

carelessness of a professional

What should you do if you make a mistake in your notes?

Don’t delete it, but make a new note and reference the error