The ChiroPadEMR section of ChiroSuiteEHR enables the modification of the SOAP notes by selecting the various options on the Documents window. The SOAP note Options are to the left of the note but right of the Icon Button Bar and are circled in red in figure 2. There are 2 columns, Force and Suppress (abbreviated SUP). The first 2 check boxes allow the selection of ALL items in the column with one click in the box.
NOTE: Selecting Suppress ALL produces a very basic SOAP note that as of this year no longer meets the minimum criteria for a note for Medicare as well as under the regulations of many State Boards. Although the option is available, Life Systems Software strongly encourages each user of the program to NOT Suppress ALL. The Force ALL selection will produce an extremely detailed note, and will contain information that was NOT entered on the current visit. The bottom line is to use these selections carefully to be in compliance with Federal (Medicare, Medicaid, etc.), State, and insurance laws, regulations, and contractual agreements.
Medicare’s requirement at the time this is being written is that each and every SOAP note must include Patient Comments and Complaint History (entered in Subjective), the physical findings on that visit (entered in Objective), the Condition Status (entered in Assessment), the current Active Diagnosis (Diagnosis tab in Assessment), and the Treatment Plan including PQRS documentation. To meet Medicare’s current demands, place checks in the Force column for Comments and DX.
If the doctor enters any special information on the visit, such as Additional Objective Information, Physical Exam data, Orthopedic/Neurological Tests, ROM (Range of Motion), DIR (Diagnostic Imaging Report), Muscle Tests, Sensory Tests, and/or Extremity data, there should also be a check in the appropriate Force box to include it in the SOAP note. For any of these items that do NOT have a box in the Force column, simply remove the check from the box in the Suppress column.
After making the selections, click on the Pencil icon at the upper portion of the window, also circled in red in figure 2. This will regenerate the SOAP note using the options selected. Remember that the Pencil icon can be clicked at any time, whether or not the Note Options have been changed. Each time the Pencil icon is clicked the SOAP note text will be randomized, and will appear somewhat different.