Most people are familiar with going to the doctor’s office. You call to make an appointment, the receptionist offers an appointment weeks away. Once you get there, you fill out long forms, present your insurance card, and pay your copay. By the magic of medicine that is all you have to think about. There are few people who recognize medicine as a business.
So what happens on the back end? Let’s review the same scenario from the office staff’s perspective. A patient calls to make an appointment. The receptionist reviews the schedule. Due to the fact that it is flu season and chicken pox is going through the local school, the schedule is full. The receptionist will ask the patient what seems to be the problem; with that information he/she will try to determine the severity of your condition. The receptionist must decide if your condition warrants moving another patient’s appointment or squeezing you in risking upsetting an entire waiting room full of patients. The receptionist determines that your routine checkup is not a life threatening situation and he/she offers you an appointment in three weeks.
The day before your appointment, the receptionist calls to confirm that the patient will be coming. This is called a confirmation call or confirming an appointment. If the patient will not be able to make it, your slot can be used to accommodate one of the many patients who are waiting for an appointment.
Prior to the patient’s appointment, a chart must be prepared. This means that the office staff must gathering any reports of tests done since the last visit (x-rays, blood work, etc…). The doctors note paper (called the progress note) must be prepared and dated and the chart must be in order – often times chronological order.
Now three weeks have passed and the patient comes for the appointment. The receptionist has the patient update their medical history, demographic information (address, phone number, and insurance information). The patient is thinking, “Why is this necessary? I was here last year”? Here’s why; things change. In a year new medications can be added, surgeries are preformed, and allergies are discovered, and people move to new houses. All of these questions are for the patient’s protection. The more information that the doctor has, the fewer medical mistakes occur.
Once the patient has completed their paperwork, they wait, and wait, and wait. The patient begins to get angry, even sometimes accosting the front desk for “over booking” or accusing the doctor of greed quenched only by seeing too many patients. Now to be realistic, what is really causing the delay? There are several possibilities. First, it could be a very chatty patient who is holding up the doctor. It could also be a patient who has trouble understanding. Worst, it could be a patient who is sicker than anyone knew and now requires more time. Finally, sometimes in the midst of outbreak, it is necessary to overbook.
Now, the patient is called and led back to an exam room. Eventually the nurse comes in and asks about the patient’s problem, takes the patient’s blood pressure, pulse and temperature. These things are called vital signs. When the doctor comes in to the room, he/she proceeds to ask questions, and touch the patient in places that do not hurt. Five minutes later, the patient is handed a prescription for blood work and told to come back next year for more of the same.
Now here is what just happened, really. The nurse took the vital signs, which the doctor will review to determine that your major organs are functioning properly and there is no immediate danger or chronic condition that may require immediate treatment. When the doctor entered, he/she asked what you may have believed were “irrelevant” questions , but these questions were actually an important part of the visit, this question and answer period is known as the subjective. The doctor listens to find patterns in the patient’s descriptions of the problem. The questions may not have a positive answer but they are relevant to the condition for which you are being treated. This subjective evaluation lets you tell the doctor what you think is wrong.
While you tell the doctor about your condition, the doctor is also looking at the color of your eyes, at the color of your skin, smelling you, watching your behavior, reaction time, and many other obvious and visible things. This is the called the objective part of the visit. The objective will establish what the doctor thinks of your description of the condition for which you are being evaluated.
During the physical examination the doctor checks pulses and feels glands that the patient doesn’t know they have. He/she feels the temperature of the skin and looks down your throat. This hands-on, touching part is called the physical examination and it is the final glue that holds what the doctor has learned in the Subjective and Objective. This leads to a diagnosis or at least a strong suspicion about what problems the patient has. The diagnosing is referred to as the assessment.
Based on this assessment (the diagnosis) the doctor will decide on the correct course of action or treatment, called a plan.
Those who are attentive will notice that the word SOAP is in larger bold text. SOAP is the foundation for how a physician is required to document your visit. All visits to the doctor must be thoroughly documented by law. This documentation is cumulatively called the patient’s “medical record”. Not only is the doctor required by law to make notes, they must be in a specific format; one of the most common formats is called SOAP (subjective, objective, assessment and plan). If the physician does not properly note the visit he/she cannot bill the insurance company for the visit, therefore he/she cannot get paid for their services. Billing the insurance for services that have not been properly documented is considered fraud and can result in large fines and possible even jail time for the physician.
The rules surrounding how a doctor must document a visit are called documentation guidelines. They were developed by the Centers for Medicare and Medicaid services and adopted by just about every insurance company thereafter. All the news that one hears relating to “Insurance fraud” relate back to documentation either directly or indirectly. Accordingly, documentation is a HUGE topic on which I will not spend much time because there is so much to cover. I do, however, recommend that the reader to some additional research.
There are two different versions of documentation guidelines. One was published in 1995 and the other in 1997. Above, I described the 1995 documentation guidelines because they are the most simple to set the stage. In practice, the 1997 are becoming more widely used, particularly with as electronic medical records make it easier to document more extensively. Still the 1995 guidelines are simple to understand and we will use these to set the foundation and understand the basic point that documentation is important.
To learn more about documentation, check out the guidelines. Here are some good resource links for you: