Don't Spend Big Bucks on a New EMR... until you read this!

This new article, published in Advance for Physical Therapists April 3rd, 2012, shows you the future of Electronic Medical Records (EMR) in physical therapists' clinics.

We cover EVERYTHING physical therapists want in a new, electronic documentation and billing system.

In the article we discuss the following:

• Physical therapists documentation
• Productivity and profitability
• SOAP notes
• Medicare Audits
• Personal Health Records (PHR)
• Electronic Health Records (EHR)
• Mobile or handheld computing
• Psychosocial factors
• Quality metrics

BEFORE you spend lots of money on a new computer system or new software you should READ THIS FIRST!

The Audacity of SOAP

SOAP notes hinder good physical therapy documentation.

SOAP notes began in the 1950's as part of the Problem Oriented Medical Record (POMR) for physician decision-making.

SOAP has been implicated by many authorities as hazardous to physical therapist decision-making.

Imagine this scenario: 

A big, fat hospital chart with specialty information: 

• internal medicine
  
• orthopedics
  
• cardiology
  
• gasteroenterology
  
• physical therapy
  

...all represented in one chart.

Clipped to the front of the chart is a single sheet of paper with the (in)famous acronym: S.O.A.P.

The doctor, whatever her specialty, needs to see the patient and do the following:

• establish the reason for the visit (S)
  
• take measurements (O)
  
• arrive at a medical diagnosis (A) and
  
• establish the plan of care (P)

Do physical therapists need to make these decisions - each visit?

*****

Do physical therapists make the same decisions as medical doctors?

SOAP hinders physical therapy notes because physical therapists make different decisions than medical doctors.

Daily, physical therapists need to assess and measure patients' activity and participation levels and make decisions based on the measurements.

For example...

"Today, I can't walk as far as yesterday because the bad weather has swollen my knee and hip joints"

Because her medical diagnosis is chronic knee osteoarthritis you decide to measure her knees and you find increased swelling, due to the weather.

You decide to alter her plan of care - instead of exercise today you want to use modalities.

You decide to recommend a cane, during the period the knees are swollen - to prevent falls.

Will your SOAP note support your decision-making?

Many authorities don't think so.

Is it time to ditch SOAP?

Do physical therapists need a proprietary clinical note-writing format?

How do physical therapists make decisions?

Physical therapists (PT) usually treat 11-15 patients per day in outpatient orthopedic clinics.

Most PTs in the United States still use a pen-and-paper approach to note writing.

We scribble all day long in between running to patient treatments.

Medicare only has these written notes to examine to determine if the physical therapy treatments are worth paying for.

What do most PT charts look like and what decisions do they reflect?

Get some perspective

Step back for a minute.

Stop writing your note.

Stop being a PT or PTA.

Look at your chart.

What does it look like?

Is it organized?

Neat?

Sequentially organized?

Are the most important documents on top?

Does it look like you chart is designed for fast, efficient treatment?

Or, does it look like your chart is designed for fast, efficient decisions?

What do skilled physical therapy decisions look like?

Your skilled physical therapist decisions are what Medicare is paying for.

Treatment is secondary to your decisions.

Make the chart work for you.

Set up your chart so that evidence of decision-making is foremost.

Put your goals at the front of the chart.

Make decisions about goals in the daily note. If you still use a SOAP note the Assessment portion should reflect progress towards goals.

Make your initial measurements accessible. Put your dictated Plan of Care where you can get to it easily (hint: not at the back of the chart).

Two types of measurement need to be accessible:

1. Impairment in body structure and function (ICF)

2. Activity and participation limitations (OPTIMAL)

Put these near the front of the chart.

Some therapists feel that the back of a double-sided, flip-type paper chart is just as accessible by grabbing the whole stack of paper and flipping it up.

Perhaps it is.

I think that putting your goals and measurements at the back of the chart however sends the subtle message that you see writing about goals as less important.

Goals are less apparent and less evident at the back.

The presentation of your chart should reflect your intent.

What is your intent?

Decisions or treatment?

Decisions are more defensible.

*****

To get an incredibly detailed, voluminous, technical and shelf-worthy resource on physical therapy do-it-yourself Medicare compliance go to the

Compliance Program for Individual and Small Group Physician Practices

by the Office of the Inspector General.

To get a compliance program written by a physical therapist for physical therapists go to

BulletproofPT.com

written by Tim Richardson, PT.

What is a SOAP note?

There is lots of confusion and controversy, mainly confusion, about what constitutes a SOAP note.
Let’s first look at what insurers require in physical therapists’ documentation:

1. Evidence of Medical Necessity for Physical Therapy
2. Evidence of Skilled Physical Therapy services – that is, the services could not have been provided by a less skilled provider such as an aide, a massage therapist or an athletic trainer.
3. The expectation that the patient will experience significant recovery in a reasonable time frame.

Nagi’s Disablement Model is the preferred model that is disseminated in the Guide to Physical Therapy Practice. The Guide is the professional consensus of what constitutes the standard of physical therapy practice.

With these criteria in mind, let’s look at the SOAP note. What must go in the note?

Subjective
A dis-ability statement, or it’s converse – an ability statement such as the following:
· “I can’t get up out of a chair”
· “I can now get up out of a chair” (satisfies the expectation of improvement criteria)
Don’t use symptom language.
· “My leg hurts”
· “My back hurts’
Symptoms are included in the initial plan of care and, by definition, don’t change much day-to-day in rehabilitative services.

Objective
Numbers.
Measure something. Standardize the measurement. Make sure any other professional in your clinic could repeat the measurement.
· Measure range-of-motion using standardized movements.
· Measure strength using standardized measurements.
· Measure balance using standardized measurements
· Measure fear-avoidance beliefs using standardized measurements.
Make sure the measurements reflect patient-identified goals from the plan of care.

Numbers provide evidence of Medical Necessity for Physical Therapy, which is required in Medicare Progress Notes but not in daily Treatment Encounter Notes. If the daily notes meet the criteria for Progress notes then separate progress notes are not required.

Assessment
Did the patient meet the goal? Are they making progress towards the goals? Did the measurement get better?
· Goal #1 is met (satisfies the expectation of improvement criteria)
· Goal #2 is not met
· Goal #3 is updated. Increase Right Shoulder Flexion in Standing to 180o.

The Assessment also provides the physical therapist the chance to update the physical therapy diagnosis: the link between the patient-identified functional limitations and the measured impairments.

Physical Therapy Evaluation and Re-evaluation is an ongoing component of the skilled service. The initial diagnosis in the plan of care may change as new information is discovered by the physical therapist. The Assessment should be used to integrate the new information with the functional limitations to formulate an ongoing treatment diagnosis.
· Inability to raise the right arm overhead is due to a weak external rotator muscle
· Inability to walk across the parking lot is due to a stiff right hip, a weak right hip external rotator muscle and lumbar instability.
· Inability to descend steps is due to a weak right knee extensor, a right knee flexion contracture and a short calf muscle.

The Assessment should require critical thinking from the physical therapist. The Assessment cannot be done by any other service.

Plan
The Plan updates or changes the plan of care. Most of the time this is done monthly, not daily. The physical therapist updates the plan based on new findings, expected progress or both.

If the Plan is not changed or updated then there is no need to write anything in this portion of the SOAP note.