Standardizing Clinical Notes for Professional Success

By Erin Cammarata
Erin Cammarata

Over the years, I have read countless clinical notes from hundreds of orthotists and prosthetists. Using those notes, I have fought audits, assessed the contents for prior approvals and authorizations and for compliance with Centers for Medicare & Medicaid Services (CMS) regulations, and just plain tried to figure out what the notes were supposed to communicate. As you may imagine, clinical notes are anything but standardized in O&P. While some are quite good, others range from very short notes with a few sentences to several rambling pages that lack paragraphs, headings, or direction. With that in mind, I have suggestions to improve your O&P clinical notes.

I recommend using the subjective, objective, assessment, and plan (SOAP) format. The SOAP format is used in healthcare because it provides standardized, well-organized documentation that other healthcare professionals and payers have come to expect. Using this format defines O&P providers as healthcare professionals.

Don't fill your notes with countless details about how you trimmed this, padded that, moved a strap, etc., to resolve fitting problems over the course of several appointments, before documenting that the fit was satisfactory. Why not? Because rather than documenting the practitioner's dedication to ensuring the device was the best it could be, the note may instead document proof that the practitioner provided a device that wasn't properly designed or well fabricated. It is much better to simply document that "minor modifications were required to optimize the fit," and then focus on the function of the device. Documentation that focuses on how well a device works for the patient is a better reflection on the practitioner's efforts.

Use paragraphs and headings in your notes. A long note without headings and paragraphs is not only difficult to read, but it's difficult to find pertinent information in as well. Make it easy for the claim auditor to find information he or she needs in specific sections of your notes. Auditors need just one reason to deny your claim, and the reason may be that they can't locate the relevant details.

For example, if the auditor will be looking for valgus instability of the knee, document it in the objective section of your SOAP note. This is, in fact, a specific requirement in the Local Coverage Determination (LCD) for Knee Orthoses. As another example, one practice I worked with created a separate paragraph heading called Ambulatory Status for every initial evaluation note for O&P patients who required a lower-limb device. This makes ambulation documentation easy for the auditor to find and documents the patient's specific gait deviations. In the delivery note, the practice then details how the device successfully addressed those gait deviations.

This leads to my next suggestion: Connect the dots for the auditor by painting a picture of the plan of care. Review your previous notes and address every issue that was documented in that note in your delivery note. If the patient had a problem that was documented in a previous note, such as balance issues, make sure you address balance in the following note.

Focus on the functional benefits of the device. CMS includes that particular language many times in its LCDs for a reason. It's what CMS looks for to justify that the device is reasonable and necessary. It is the primary reason why orthotists and prosthetists provide devices in the first place-O&P services are prescribed to provide functional benefit to the patient. So make sure you identify that benefit, and document how the device provides it.

As a profession, we need to train ourselves to write more standardized, professional clinical notes. SOAP notes that clearly document all the requirements in the LCDs will be your most effective way to create that standard. Communication through documentation skills in our clinical notes will not only define us but is essential to our success.

Erin Cammarata is president and owner of CBS Medical Billing and Consulting. For more information, contact .