Medical Documentation: Efficient vs. Personalized Treatment

Doctors vs. Insurance: Personalized Treatment vs. Efficient Treatment

As a consumer of medical care and medicine it is probably frightening to see that these two are at odds with each other, but this is the reality of physicians today. When you think of efficient care you probably think skilled and competent care. The insurance companies definition of efficient lies more toward cost efficient. Physicians often walk a fine line between what is best for the patient and what insurance will cover. It is a difficult balancing act.

Wrong Goal Tiles

Should health insurance’s want of a more efficient billing system trump a more personal approach of record keeping by medical professionals?

Insurance companies are now suggesting that medical professionals change the format of the documentation that is used for notes for patients. The traditional format of SOAP notes have long been used by medical professionals to record and track patient visits and progress.  As a massage therapist, I have been trained to use SOAP notes for medical documentation. I find SOAP notes are efficient and readily provide vital client information that I need for each session.

What are SOAP Notes?

SOAP notes are the medical documentation that medical professionals use to write notes about a patient visit. SOAP notes provide summarized pertinent information that a doctor or therapist need to know about a patient’s or client’s condition.  SOAP is an acronym for:

  • S – Subjective which is the patient’s complaint and description of pain and symptoms
  • O – Objective which is the medical professional findings through observation, examination and testing
  • A – Assessment which is basically the diagnoses
  • P – the treatment Plan

Many therapists and doctors rely upon heavily upon the Subjective component of the notes.  It is crucial to be able to track what the patient or client perceives is happening in their body:

  • What has changed?
  • Is the pain better or worse?
  • How do you feel after prescribed or suggested treatment?
  • Have you had any adverse reactions to treatment?

These are just a few of the questions on which medical professionals need the patients input. This allows not only for open communication between doctor and  patient, but also provides a history of the patient’s condition.


SOAP Notes Are Changing To MEAT Notes And Why You As A Patient Should Care

Blue Cross and Blue Shield as well as other insurance companies are now suggesting and implementing a change to MEAT documentation. The acronym breaks down as follows:

  • Managed:  Documentation of the most recent conditions treated
  • Evaluated: Doctor observation, examination and testing
  • Assessed: Diagnosis
  • Treated: Documentation of treatment plan

The Missing Component, You The Patient!

Do you see what is missing? The Subjective component, the patients input! Patient input has been taken out. It seems they are tracking away from patient input into strictly medical findings. But this does not work. There are times when a patient’s complaint that was first thought not to be as significant may later prove to be the key in a diagnosis.

Medical Coding For Billing Trumps Uncertainty

In his article, Bad Ideas In Medicine: Blue Cross Tells Me How To Practice, Dr. Peter Lipson points out that using words such as “history of ( ), “probable”, and “rule out” are now discouraged in documentation.

Apparently these terms express something that is unbillable: uncertainty. Dr. Peter Lipson

The human body is complex and often perplexing. There are times that the history of a previously diagnosed condition could be a probable cause of new symptoms, but additional time may be needed to rule out other symptoms or causes.  In other words, it may take time to come to a firm diagnosis.

It seems that insurance now wants an absolute diagnosis right away. Right or wrong…  And if an absolute diagnosis is given, then it is logical to assume that treatment will follow.  Right or wrong…

Assembly Line Medicine

Medicine is not always cause = effect. There are many variables that can affect a diagnosis. However, the MEAT documentation and some of the new medical coding does not allow for many of these types of variables. It is data driven, to expedite not only billing but seemingly face to face time between medical professionals and their patients. By eliminating many of the variables that occur with individuals we are moving toward an assembly line approach to medical treatment which will increase profits while decreasing personalized treatment.

The Guise of Efficiency Will Add To Physician Work Load

Talk to your doctor.

Keeping the lines of communication open with your doctor will help lead to more personalized treatment.

Of course most doctors and therapists will continue to document patient dialog of complaints, pain and symptoms, even if the MEAT documentation becomes the standard note. Ironically, what is supposed to cut down on paper work, simplify medical billing and save time is going to probably going to do just the opposite.

What You Should Do As A Medical Patient

The take away for patients is that  now more than ever it is important YOU document your medical appointments. Keep a notebook that notes your explanation of pain and symptoms to your doctor.  Note your doctor’s comments, suggestions, prescribed medications and treatment plan. By doing this you will have your own running health history that will come in handy as a reference for questions that your doctor may have regarding your previous ailments.

Keep The Lines of Communication Open With Your Doctor

If a comment by your doctor, something about the treatment or prescription is questionable to you, ask your doctor about it! Do not blindly assume that the doctor always knows best. Patients often will follow doctor’s orders even if they are doubtful. Ask questions. Ask for explanations. Ask for clarification. And if you are not satisfied, get another opinion.

This is meant to be a heads up to patients; I am not criticizing medical professionals, they must work within some boundaries that are often out of their control. It is important that you the patient start taking a more active approach in your healthcare. This will not only benefit you, but will also benefit the medical professionals trying to help you.


Just for clarification: I am not a doctor. I am a massage therapist with advanced training in musculoskeletal system function.  I cannot diagnose, prescribe meds or treatments as a therapist, but I am licensed to treat muscle tension and injury. If a client’s problem is beyond what I am licensed to treat, I refer that client to a medical doctor for evaluation.

 

 

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