The Prior tab (figure 7) lists all past SOAP notes in date order, the most current note on top and the oldest note at the bottom of the list.
Figure 7
In addition to the date of the SOAP note, the Category and Created By columns are displayed.
Provided that the SOAP note was categorized when it was generated, the Category column shows the type of note that was entered. The Category makes it easy to locate specific information if and when it is needed. The Category list can be modified (create, edit, delete, etc.) in the Customization section.
The Created By column identifies the individual in the practice that created the SOAP note. This is based on the staff member that logged on to the work station on which the SOAP note was created.
ChiroPadEMR provides the ability to edit Prior SOAP notes. However, this MUST be done in the correct manner or the provider will be accused of fraud. Remember that there is a HIPAA/HITECH Audit Log that records the date and time of every entry in the system. If an auditor finds a discrepancy, meaning that a change was made in a SOAP note and was NOT logged correctly, then very severe penalties could be imposed. At this time, the Medicare requirement is that the SOAP note MUST be completed within 72 hours of the patient’s visit. Medicare has indicated that this time frame may be reduced to 24 hours at some point in the future.
Editing the SOAP note is easy. On the Prior tab, click on the date of the SOAP note that is to be edited. The selected SOAP Note will appear in the large text area below the list of Prior notes. At this time, if the change is being made within less than 72 hours of the visit, it may not be necessary to enter the change as an Addendum, but is still advisable to do so. Any change that will be made in an existing SOAP note AFTER the 72 hour time limit must be entered as an Addendum.
At this point, it is advisable to open Paraphrase (figure 8) to follow the format required by the laws of HIPAA/HITECH and the Omnibus Rules that apply to making changes to an existing SOAP note. Open Paraphrase by clicking on Tools and then selecting Paraphrase.
Figure 8
Once Paraphrase is open, from the Category drop down box, select Addendums. (figure 9).
Figure 9
Click on and hold down the left mouse button on the Addendum Notice item in the Drag & Drop Mnemonics list. Using the mouse, drag the Addendum Notice to the location in the SOAP note where the information needs to be entered. Release the left mouse button and the Addendum format will appear in the location selected (figure 10).
Figure 10
Now type in the appropriate information in each location of the Addendum for the current date, the reason the addendum is being created, what is the addendum and who is making the entry.
Between the Date List of Prior Notes and the Display box, there is a Word Processing Tool Bar (figure 11). To use the Word Processing Tool Bar, highlight an item or section within the SOAP note and click on the word processing feature that is desired.
Figure 11
Once the editing has been completed, click on the Save icon in the upper left of the Documents window.