Chiropractic Software by SOAPe

One of the most challenging obstacles we face as chiropractors is documenting medical necessity, especially as a patient’s care progresses beyond the acute phase. If you are unable to document medical necessity, it is unlikely you’ll be reimbursed for the care you are providing or be approved for additional visits by an insurer. Ultimately, this can lead to a significant loss in revenues for your practice and patient dissatisfaction. Chiropractic care is considered medically necessary when your documentation can show that your treatment is expected to significantly improve or resolve a condition and when continued care will result in functional improvement. Once the clinical status stabilizes, without expectation of additional objective clinical improvements, further chiropractic care is considered maintenance.

Setting Goals

One of the best ways to document improvement is by establishing both short-term and long-term goals. These goals should be clearly defined in the Initial Report. You should also establish a feasible timeline in which to achieve these goals. The biggest mistake chiropractors make is setting goals that are not objective, quantifiable, or functional. Your daily chiropractic SOAP notes should intermittently reflect your patient’s progress in relation to the treatment goals that were established during the initial visit.

Short-term goals are set to provide an immediate, achievable target. Short term goals might constitute daily, weekly or monthly achievements. Long-term goals are set to help patients understand what they can expect from the care you are providing and where they can expect to be in several months. It’s important to use the long term goals as a means to help motivate a patient to achieve their short term goals.  The goals may be changed if people become unwilling or unable (financially or otherwise) to continue or if they progress more slowly or quickly than expected.

Examples of short -term goals might include the following:

1. Reduce pain and restore normal joint function and muscle balance.
2. Improve lumbar range of motion by 20 degrees each month.
3. Improve hamstring flexibility by 5% each week using PNF stretch.

Examples of long-term goals might include:

1. Restore full lumbar range of motion in 12 weeks.
2. Improve hamstring flexibility by 50% in ten weeks.
3. Restoring functional independence and tolerance to normal activities of daily living.

Your monthly Progress Reports should address progress toward the patient’s goals, otherwise insurers will view the treatment as medically unnecessary and refuse reimbursement. Simply stating that “the patient’s range of motion has improved” is not sufficient. A more appropriate statement would be “The patient has successfully achieved the short-term goal of improving lumbar range of motion by 20 degrees in 4 weeks. We will continue to work towards full restoration of the patient’s lumbar range of motion over the next 8 weeks through the use of chiropractic adjustments, modalities and therapeutic activities and exercises.”

SOAPe Platinum software can help chiropractors to streamline the process of documenting medical necessity. Our point and click interface makes it simple to establish both short and long-term goals for your patients, and document their progress adequately. We continue to improve SOAPe Platinum software to meet the growing needs of the chiropractic profession while boasting the lowest pricing in the industry.

Comments are closed.