Healthcare documentation is a critical component for your holistic practice, both in terms of delivering great care to your patients and for insurance billing purposes-not to mention the importance of having some form of documentation in the event of a legal situation.

Treatment notes are needed to keep a live record of how your patient is feeling and what plans have worked in the past or what needs to change for the future; keep reading to learn more about a particular outline of healthcare documentation called SOAP notes and how they can play a role in your holistic practice's insurance billing cycle.

One standard form of healthcare documentation is called SOAP notes, which stands for Subjective Objective Assessment and Plan. Each section of this general formula is key to gathering a comprehensive report of the patient's current experience and determining the best treatment plan.

This is the first section of SOAP notes and pertains to the subjective experience of the patient you're treating; this includes their feelings, perspective, and personal views as relevant to the treatment setting. The purpose of this section is to provide context for why the patient is visiting your holistic practice and to allow the patient to put into their own words what is going on with them.

Depending on the setting of your holistic practice and what type of treatments you offer to your patients, this section might have a few other subheadings to further elaborate on what the patient is experiencing.

This initial section is important for illuminating how a patient's condition is affecting them so that you can determine how best to address their pain points-both literal and metaphorical.

As opposed to subjective, this second section deals with objective, unbiased facts regarding the patient's condition. Such information might include:

It's important to distinguish between symptoms and signs in this section; symptoms are considered subjective, whereas signs are considered objective notes. As with all medical documentation, it's also crucial to filter out any kind of assumptions in the note-taking process; each objective note should be verifiable through evidence.

This third step of SOAP notes is where you bring together the subject and objective portions of your documentation and determine what might be ailing your patient. In this section, you might list whatever problems or diagnoses that patient is presenting with, in order from most to least important or severe.

The assessment portion of SOAP notes is important because it provides documentation of the diagnosing process and serves as a record of your thinking. Assessing the patient is helpful for other providers to review your conclusions and inform them on how best to deliver holistic care from their specialty or perspective.

The final step in writing SOAP notes is, of course, to outline a plan of care for the patient you're serving. 

The plan section is an essential conclusion to the SOAP notes outline because it provides the appropriate next steps and pertinent information for the patient to follow in order to begin their plan for treatment.

The phrase "If it's not documented, then it didn't happen" might sound extreme, but in the world of healthcare-whether medical or holistic-it's the norm. Treatment documentation is essential because it functions as part of the patient's medical history, enables collaborative care between providers and authorized entities, results in a better quality of care, and more.

SOAP notes are simply one outline to follow when doing healthcare documentation; it's an easy acronym to remember yet ensures that all cornerstone portions of a patient's experience are documented. From the patient's subjective experience and reported history of their ailment, to what your recommendations are for treatment, SOAP notes provide a comprehensive record that can be referred to in the future.

SOAP notes are also important for insurance billing purposes; because healthcare documentation is an essential part of operating a successful holistic practice, it's vital that your insurance billing process is as streamlined as possible. 

With precise, consistent documentation comes better patient outcomes. This, of course, helps insurance companies regulate the cost of healthcare because improved patient outcomes are the result of efficient and effective care.

As you well know, you can't just willy-nilly code a patient-provider interaction with just any kind of coding; you need to back up your medical billing and coding with evidence of why you're submitting a claim for that interaction! SOAP notes and healthcare documentation overall help justify why you're submitting a claim for reimbursement.

Finally, precise, comprehensive documentation that follows a logical line of reasoning is an effective way to reduce the risk of malpractice claims at your holistic practice. It's hard to justify any kind of treatment plan or diagnosis without evidence, so SOAP notes and other forms of healthcare documentation are essential to reducing your practice's risk in terms of delivering misguided care.

Antonio Arias, MBA, CHMBE, is the CEO of Holistic Billing Service, an integrative health services firm focused on streamlining your documentation, billing, and coding process to enhance your revenue cycle management. See holisticbillingservices.com