SOAP Note Documentation
The problem with most of the computerized SOAP note programs that are out there is that there are 2 sets of faulty assumptions:
Faulty Assumption #1: The programmers assume that
chiropractors know how to
Faulty Assumption #2: Chiropractors assume that the
programmers know how we're
supposed to document.
After evaluating countless electronic SOAP note programs on the market and being quite underwhelmed, I was approached by a software company in Florida that has been producing and selling software for chiropractors for the last 25 years. They asked if I wanted to customize a SOAP note program they had and put my own twist on it. After more than a year and a half of working on it, I gave it a run - and even I was amazed at what I was able to do!
I call it "Got Documentation SOAP Note Program." When designing it, it looked through 3 different lenses:
1. I've been in practice since 1987 and I've talked with a ton
of chiropractors all over the country. I have a good feel
for the way most of us flow in our offices.
2. I teach documentation seminars and have a thorough
understanding of the various documentation
requirements and nuances.
3. I review records and perform IMEs for insurance
companies for PI and WC cases. I know what
they're looking for and I understand their perspective.
To see more about the Got Documentation SOAP Note Program, please click HERE.
Here are some demonstration/training videos you can watch:
Regular Patient Videos
Video 1: Adding a New Patient - click Here.
Video 3: Documenting Review of Systems - click Here.
Video 4: Documenting Outcome Questionnaire Scores- click HERE.
Video 5: Documenting the E/M Exam - click HERE.
Video 6: Documenting the P.A.R.T. Exam on Daily Visits - click HERE.
Video 7: Documenting Assessments and Diagnoses - click HERE.
Video 8: Documenting Treatment Performed on Daily Visits - click HERE.
Video 9: Documenting Treatment Plan and Goals - click HERE.
Video 10: Documenting Subsequent Visits - click HERE.
Video 11: Documenting Re-Exams - click HERE.
Personal Injury Videos
Video 1: Documenting 1st Visit Subjective Complaints - click HERE.
Video 2: Documenting CRMA - click HERE.
Video 3: Documenting Causation - click HERE.
Video 4: Documenting the Croft Guidelines for the Tx of CAD Injuries - click HERE.
Workers Comp, Slip and Fall and Maintenance Video
Video 1: Documenting the First Visit - click HERE.