Posted in Insurance, My services, Practice Fusion EMR, Training

Improving documentation in EHR SOAPs will save you time!

Recently, I had a client (provider) with many denials that were denied with the language similar to: “submitted information does not support treatment for the patient, please submit medical record (notes) for review and a corrected claim”. In this particular case the client (provider) has dealt with the payers for, at the time when I started working with the client, months. The provider sent in the requested notes yet still received the same denials.

I am sure some of you can relate to this and the first word that comes to mind is the “F” word. Yes, FRUSTRATION. LOL. I know it might have been another word, but let’s keep it professional.

Anyway let’s get back to this specific situation. The solution to these denials seemed simple, but it was not. Why? Well, in this particular case the provider wrote SOAP notes in short-hand. Now, why is this so important?

Time OUT!

Yes, yes, I know with today’s medical office structure and atmosphere and the rules that payers and the government have imposed upon the providers, there is just no time to write more detailed documentation in those darn EHR SOAPS. So, one solution- writing short-hand.

Although, this does reduce the ‘initial time” for documentation; it does increases the time in a long-run, when you have to file 2 or sometimes 3 appeals for denied claims and wait weeks or even months for an answer.

In this particular case – even I could read and understand the short hand. No I am not a doctor but I do work with a doctor in the same medical field of Allergy, Immunology and Asthma; handle her billing, denials, and writing Consultation reports to Primary Providers. Yes that experience  DEFINITELY helps me when I do my consulting/training work.

Unfortunately, I am not the one who is reviewing these notes and reimbursing the provider for that treatments, it’s the payers job. So, spending couple of hours a week and use as much detail in you documentation of the patient treatment, procedures or patient plan, WILL save you time in the long-run. Adding something as simple the sample given below, would save you weeks and/or even months (like in this given situation) waiting for an answer or payment.


Procedure: Administered treatment of Albuterol Sulfate Inhalation solution of 0.083% to the patient, for 7 minutes. The treatment was administered in Office Setting. Patient peak flow before treatment: ________ Patient peak flow after treatment:_________

Now it’s your turn: does your office have a lot of denials and requests for medical records? Do you find yourself or your medical office staff appealing claims 2 or more times? Let me know what you do to hopefully avoid this dreadful issue.



My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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