SOAP (Subjective, Objective, Assessment, and Plan) notes have been the cornerstone of medical documentation since Lawrence Reed introduced the “Problem Oriented Medical Record” in the 1950’s. Before the dawn of SOAP notes, medical practitioners of Reed’s time had no standardized method of record-keeping. Instead, each provider would scribble notes in their own fashion, making insurance reimbursement, coordinated care, and chart review difficult and time-consuming.

Today, all medical practitioners—including drug and alcohol counselors, behavioral health techs, detox nurses, and physicians—rely on SOAP notes to document day-to-day treatment progress. 

Although SOAP notes are ubiquitous in the behavioral health field, errors, oversights, and inaccuracies often riddle these documents. Today we’ll look at 4 ways to improve your behavioral health center’s SOAP notes that you can start using today to clean up your documentation and ensure smooth revenue cycles. 

SOAP Note Improvement #1: Use an EHR That Double-Checks for Errors

When creating a SOAP note, there is a lot of room for error. When the volume of patients is high and the clinician is strapped for time, the number of errors increases. Whether information is omitted, details are transcribed incorrectly, or a note is attributed to the wrong patient, the results can be inconvenient in some cases and downright catastrophic in others. 

Documentation errors are incredibly common in all medical practices and the substance abuse treatment space is no different. 

Because human error is inevitable regardless of the setting, the common wisdom to avoiding errors in SOAP notes is to always double-check your work. At Behave Health, we encourage this as a best practice but the truth is this won’t always be possible due to time constraints. For this reason, it’s important to choose an EHR that double-checks for errors for you. 

That’s why we made Behave Health’s EHR with SOAP note error-minimization in mind. Our smart software not only makes documentation quick and easy with ready-made templates, but it also scans your work for potential errors—including timing inconsistencies, blank SOAP note fields, and other details that commonly result in insurance denials. 

SOAP Note Improvement #2: Allow for Complexity 

While concurrent documentation can help speed up the note-taking process and keep patients engaged in their care, it’s important not to jump to the keyboard too quickly. 

Go into your SOAP notes with a plan and a basic outline of what the chief complaint is. Oftentimes—and especially in the addiction treatment world—there is more than one factor at play in a patient’s disease process. Frequently, mental health issues like depression and anxiety present alongside behavioral health issues like Substance Use Disorder. 

Completing a straightforward SOAP note regarding Substance Use Disorder only to discover upon further conversation with the client that they are also presenting with symptoms of a mental health concern is frustrating. Revising inaccurate SOAP notes is more time-consuming than writing them correctly the first time. 

For this reason, it’s important to allow for complexity in your SOAP notes and take your time with the client before jumping straight into documentation. 

SOAP Note Improvement #3: Connect Assessment with Intervention 

Without a proper rationale for treatment, no insurance company will reimburse your addiction treatment center for services rendered. 

When it comes to SOAP notes, the old axiom, “If it’s not documented, it didn’t happen” rings true. 

Be sure to support the “P” (or Plan) section of your note with comprehensive “S” (Subjective), “O” (Objective), and “A” (Assessment) sections. Attention to detail in each of the sections is at the heart of every successful SOAP note. Always draft SOAP notes with reimbursement in mind and write your notes so that anyone—an insurance company, a lawyer, a family member—can understand and follow the logic behind your plan. 

SOAP Note Improvement #4: Keep it Concise

Simply put, SOAP notes are not the place to ramble. Keep documentation thorough, but keep it as short as possible, too. Precision of language and clarity of thought is important here. This is another reason to pause and gather some basic information before jumping into concurrent documentation. Doing so makes it easier to filter the extraneous information from the vital details that need to be included in your SOAP note. 

Keeping SOAP notes concise shows respect for your fellow practitioners’ time and makes it easy to access the information you’ve written in the future for coordination of care. It also makes it faster for you to review your notes for accuracy when you’re done. 

This is another place where choosing the right EHR for your center will make a big difference. At Behave Health, we have many useful templates for drafting concise and accurate notes specially designed for maximizing insurance reimbursements for addiction treatment providers. 

Improving Your SOAP Notes is an Excellent Way to Invest in Your Addiction Treatment Business 

Stellar patient care and easy insurance reimbursement starts with pristine SOAP notes. Mastering the process can take time, but it doesn’t have to if you’re using the right EHR from the beginning. With features like easy templates for individual and group notes and smart error detection, Behave Health’s EHR makes creating SOAP notes for addiction treatment providers a breeze.

Why not get your free trial of Behave Health’s all-in-one cloud-based treatment center management solution today?