We at MediGraph continue to
emphasize the importance of RAC sensitive documentation. Our
preventative approach is designed to protect you from the RAC auditors’ goal of
extracting a refund from you. RACs do not care
if the patient got better! RACs only care if your
documentation meets their standards. You could be the best
therapist in the world and it would not matter to an auditor.
Unless we understand that the RACs purpose is to obtain a refund for past
services rendered we are missing the boat. Please consider
these SOAP Note suggestions to emphasize disablement (loss of function):
Subjective: When using the
MediGraph Daily Note Editor,
the third choice in the Subjective menu is ‘Functional Complaints’.
Functional complaints are also listed in the “Area Specific” drop down
menu. The ‘Subjective’ entry of your progress notes should include personalized
patient functional complaints. For example: Mr. Smith states, “He
has pain and weakness in his knee (impairments). He also
states that he cannot get up from a chair independently, and that he cannot walk
more than 10 feet once standing (functional disablement).” If Mr.
Smith had pain and weakness, but did not have
decreased function, the medically necessary component of your treatments will be
challenged and you may be forced to refund the fees for Mr. Smith’s treatment
(all of the fees).
Objective: Please Measure Something!
MediGraph is the
only program available that integrates hundreds of standardized and peer
reviewed measurements of impairment and function within the documentation
program. Use these objective tools to substantiate the
patients impairments and functional deficits.
For example, Mr Smith has knee complaints of weakness, pain, inability to
transfer, inability to ambulate more than 10 feet. Measure Mr.
Smith’s loss of strength (an impairment), preferably with a hand held
dynamometer (HHD).* However, impairment measurements
are not sufficient to satisfy the need for intervention. To
justify treatment, a functional deficit must be present (inability to transfer,
inability to walk). Use a functional test to reveal Mr.
Smith''''s disablement-functional deficit. Have Mr. Smith
perform the Tinnetti (balance and initial gait testing), the TUG, or any
functional test to demonstrate that his functional ability has been objectively
assessed. Also, employ the functional outcome
questionnaires in MediGraph
(OPTIMAL, Lysholm Knee Rating, Musculoskeletal Function Assessment, etc.).
Assessment: Obviously, the assessment portion of the note will address
the patient goals. However, many therapists do not use the
assessment portion of the SOAP to update the diagnosis, and to link the updated
diagnosis to the patients’ functional improvements. For
example, “Mr. Smith HHD reveals strength gains of 20% (impairment improvement),
which has translated into increased ambulation from 10 feet to 20 feet
(functional improvement). Mr Smiths performance on
the TUG test reflects a functional improvement of 25%.”
Plan: The Plan portion of the SOAP note is primarily employed to alter
the treatment plan. The plan should be updated when new
findings are discovered, expected, and to revise goals as the result of these
findings. The Plan portion of the note does not need to be
completed on a daily basis.
All the tools to outsmart the RACs are at your disposal in
of the components mentioned above are included in your subscription.
Our goal is to assist you with using the software to protect you from
those predators that are only rewarded by obtaining a refund from you. Please
call with any questions.
Tom Kane, PT