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The Importance of SOAP notes in an EHR

The SOAP (subjective, objective, assessment, and plan) note is one of the most commonly used forms of documentation in the healthcare industry today. Changing needs and increasing complexity in medical care have prompted questions about SOAP’s ongoing relevance.

With the appropriate EHR integration, SOAP remains useful for current healthcare needs.

History and Origins of the SOAP Note

In the early 20th century, there was no standard for health documentation. Dr. Lawrence Weed sought to create a more disciplined method for recording patient data.

Weed first developed problem-oriented medical records (POMR) in the 1950s. His revolutionary way of recording and monitoring patient information helped providers and facilities communicate more efficiently and keep more organized patient data. Weed’s POMR system evolved into the modern SOAP note.

How to Use SOAP Notes
The acronym SOAP involves the steps that providers should follow for entering patient data, starting from their first encounter with the patient.
1. Subjective: The Subjective step is how the patient describes their condition and reason for seeking care. This may include struggles with substance abuse or feelings of depression. The clinician should note all symptoms mentioned, as well as medical history, family health history, and changes in functioning.

2. Objective: This step includes specific measurements, test results, and exam findings. It may include current medications and other treatments. The clinician should include any changes from previous tests, if applicable.

3. Assessment: This section combines the previous two to establish a diagnosis. It may include a differential diagnosis if the patient’s condition changes or there is no specific diagnosis.
4. Plan: This section includes the clinician’s plan for treatment. This may include referrals or medication-assisted treatment (MAT). The plan should also include specific goals and scheduled follow-ups.

SOAP information helps improve quality of care and justifies a clinician’s charges in a third-party payer audit.

Current Concerns About SOAP Notes

Acronym order
Some clinicians have suggested changing SOAP to APSO, speeding up ongoing care and reducing the time needed to find the assessment and plan. Others have argued, however, that the APSO order could make a patient’s input appear less important. It may also make a clinician less inclined to conduct more thorough examinations.

Recording changes

Another concern about the use of the SOAP note is that it does not explicitly state where to record changes over time. Behavioral health and addiction treatment often involve complex conditions treated over the course of months or years. With the right EHR, however, SOAP notes can easily incorporate changes to a patient’s condition, treatment, and goals.

Including SOAP Notes in EHR

Including SOAP templates in a behavioral health EHR has numerous benefits. For example, BestNotes EHR solution provides:

Greater efficiency by eliminating double data entry
Autopopulating data from the EHR’s treatment plan section, such as diagnosis, goals, and interventions
Ability to review historical SOAP notes
Incorporate data points that make up the Golden Thread
Incorporate data from Outcome Measures

An EHR that supports SOAP

As an addiction treatment and behavioral health provider, your clients have complex needs. Your best EHR option is tailored to those unique needs.

BestNotes EHR offers progress notes, medication management, and a host of other features that improve your care while reducing costs. Contact us today to find out more, and try us out for free!

date:  Jan 21, 2019
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What Should You Know About Population Health Management?

Healthcare leaders frequently use the term “population health management,” despite persistent confusion about what it means and how it is applied.

Here we offer the basics of population health management and what it means for your behavioral health practice.

What is population health management?

Despite its widespread use, many experts disagree on the precise definition of “population health.” Generally speaking, population health means exactly what it sounds like: the health needs and concerns within a specific population of people.

In the American Journal of Public Health in 2003, Dr. David Kindig and Dr. Greg Stoddart suggested that population health be defined as, “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”

For population health management, then, providers and payers can incorporate patient data with health IT solutions. This will help them track health trends and determine the best strategies for patients within that population. This, in turn, can also improve both clinical and financial outcomes for providers.

Why is population health management important?

As payers and other healthcare decision-makers increasingly focus on value-based care, and thus patient outcomes, population health management becomes a greater concern. Regardless of how experts specifically define the term, the main idea of population health is to focus on outcomes.

Based on the 11th Population Health and Care Coordination Colloquium in Philadelphia, the journal Population Health Management in 2011 listed three main goals of population health management as:

Maintaining patient health
Reducing patient health risks
Providing or coordinating appropriate patient care

The first two goals focus on prevention, an important factor in value-based care. The third goal involves care management. For behavioral health and addiction treatment providers, this usually includes improvements to patient self-management and medication management, as well as reductions to the cost of care.

What do behavioral health providers need for population health management?

A successful population health management program usually calls for a software solution that lets behavioral health practices collect and analyze data to establish a full picture of each patient. Ideally, providers then use this data to track and improve clinical outcomes and lower costs.
Behavioral health population health management should use both clinical and business solutions to make the practice more efficient as it improves patient care. Clinicians and administrators both should be able to obtain real-time insights to identify care gaps within the patient population. This helps them maintain a successful population health management program that leads to better outcomes and cost savings.

The right EHR can help your population health management.

For behavioral health and addiction treatment providers, patient populations tend to have complex needs with concurrent conditions. Behavioral-health patient populations often struggle with chronic pain and other disease, substance abuse, and mental-health disorders like depression. This creates additional challenges for providers focused on population health management.

To be successful, your population health management program should include an electronic health record (EHR) solution tailored for your practice’s specific needs. BestNotes EHR is designed specifically for behavioral health and addiction providers, with important features such as medication management, progress notes, lab ordering and tracking, and treatment plan reviews.

Contact BestNotes today to learn more about how we can help your population health management plan succeed.

date:  Jan 09, 2019
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Choosing a Substance Abuse Software for Your Practice

Not all electronic health record (EHR) software solutions are created equal. As a substance abuse professional, you should be able to choose a software solution that has your specialty and facility’s specific needs in mind.

Here are six things to look for in a substance abuse EHR:

1. Designed for Substance Abuse

Substance abuse professionals may be tempted to choose a generic EHR product that seems to do “enough,” especially if they have “decision fatigue.” However, general EHR software may not include all the features you need as a substance abuse treatment provider.

Make the choice easier by limiting your options only to those EHR solutions specifically designed for substance abuse and addiction treatment. Once you have narrowed down your options, look for EHRs that can be further customized for your practice, and can be updated and adapted if your needs change.

2. Treatment Plan Support

Substance abuse is a complex health issue that calls for a variety of treatment options, some of which may be long-term or even lifelong. Sometimes the provider and client have to try several different treatment options before finding the best one.

Therefore, your substance abuse software should also support different treatment plans. This includes both short- and long-term goals, with the ability to track outcomes and follow the “Golden Thread.”

3. Coordinated Billing

Substance abuse and addiction treatment providers also face the challenges of coordinating care across different diagnoses and treatment plans. Your substance-abuse software should include coordinated billing to streamline this process and reduce those challenges.

Look for an EHR solution that helps simplify your billing and reduce errors, making staff more efficient and reducing the risk of burnout. Make sure your chosen EHR allows you to create invoices, track billing, and partner with outside billing contractors.

4. Medication Management

Substance abuse and addiction treatment clients often have multiple diagnoses, requiring multiple medications. To help streamline care, make sure your substance abuse software includes medication management.

Clinicians should be able to use substance abuse software to create electronic prescriptions, such as antidepressants or medication-assisted treatment for addiction. The EHR should help monitor client medications and warn of any possible interactions.

5. Thorough Training for Use

Whichever EHR software solution you choose, the vendor should ensure smooth training and implementation, preparing all users for the new system. Choose a substance abuse software solution with training, tutorials, demos, regular updates, and easily accessible support.

Look for vendors that provide free demos. This is a great time to learn more about the EHR vendor, making sure they provide the customer service you need.

6. Vendors Support Best Practices

In purchasing substance abuse software, you enter into partnership with the software vendor. This vendor should be knowledgeable not only about their own products, but your specialty, as well.

Consider an EHR vendor that is a member of a reputable industry group, such as the HIMSS Electronic Health Record Association. This ensures that you are working with a solutions provider that is committed to industry best practices and has access to the latest knowledge.

Created With Addiction Treatment and Recovery in Mind

BestNotes’ EHR system is an all-in-one solution that is designed specifically for the needs of substance abuse professionals. Use it to manage admissions, intake, assessments, treatment plans, medications, billing, lab results, and more.

BestNotes also provides flexible pricing, month-to-month contracts, and user support. Contact us today for a free demo.

date:  Dec 31, 2018
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Why does the Golden Thread matter for addiction treatment professionals?

When addiction treatment professionals are able to follow a client from intake through different services and treatments to an outcome, they are said to be following a “Golden Thread” of information.

This Golden Thread should be able to “pull” relevant client data from one service or stage of treatment to the next. Proper documentation and progress notes are vital to this process.

How does the Golden Thread work in addiction treatment?

Addiction treatment can be a lengthy process that brings together different professionals to guide a client through the process.
Clients may receive different services or enter different programs, such as residential treatment centers, group therapy sessions, and medication-assisted treatment. They will interact with clinicians, therapists, social workers, medical assistants, and others in the process.
All these different addiction treatment services require some form of documentation, whether basic client demographics or complex progress notes.
The Golden Thread weaves all of a client’s relevant clinical information into all their documentation.
The Golden Thread of addiction treatment begins with the intake assessment, including symptoms and a diagnosis.
Once the problem is identified, the Golden Thread then connects to client and provider goals, as well as the creation of a treatment plan with different interventions.
The Golden Thread then pulls together progress notes that list the services provided, how they were appropriate to the addiction treatment plan, and what the outcomes were.

Like an embroidery pattern, the Golden Thread should weave information into client documentation to tell the story of their addiction treatment journey.

Why is the Golden Thread important in addiction treatment?

Among addiction treatment professionals, the Golden Thread is valuable for ensuring compliance, aiding reimbursement, and improving quality of care.

Billing: Maintaining the Golden Thread through client documentation helps ensure correct billing for addiction treatment providers and payers. Information will be correct and thorough regarding a client’s symptoms, diagnosis, and progress notes.
Auditing: Addiction treatment providers will benefit from the Golden Thread in case of an audit by insurers, regulators, and other entities. Auditors can follow client data to get a full picture of intake, symptoms, diagnosis, and how patients are being treated.
Patient care: The Golden Thread requires addiction treatment providers to help clients establish goals and objectives for their addiction treatment. It also calls for providers to create and follow their clients’ progress notes, which helps track them from intake to discharge. Providers can gain better insight into what is or is not effective in a particular patient’s treatment plan.
Best practices: One of the best ways to maintain the Golden Thread is collaborative documentation, a process recommended by the U.S. Substance Abuse and Mental Health Services Administration. With collaborative documentation, both clinicians and clients are engaged in documenting assessments, services, and progress notes. This can help addiction treatment professionals work with clients to create a Golden Thread “narrative.”

The right EHR pulls the Golden Thread.

The Golden Thread requires thorough, effective documentation, which makes efficient EHR software highly valuable. Addiction treatment providers require EHR systems that have the reporting capabilities to add and track relevant client information.

Bestnotes EHR has the reporting capabilities necessary to collect data and create progress notes so addiction treatment providers can follow the Golden Thread through each client’s documentation. Contact us today to learn more about our EHR solutions can save you time and effort.

date:  Dec 17, 2018
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Is Drug Rehab a Better Alternative to Prison for Offenders With Substance Abuse Issues?

Sending offenders to rehab instead of prison could have numerous benefits, some research suggests. Drug and alcohol rehabilitation may provide some relief for the ongoing opioid crisis, prison overpopulation, and rising government debt.

Drug rehab and addiction treatment for offenders saves money for communities and individuals.

An estimated 50 percent of the U.S. prison population has a drug addiction issue, but only about 10 percent actually get the necessary help. Sending many of these offenders to rehab rather than jail or prison could help save money in the following ways:

Individuals in addiction recovery are less likely to be arrested again, which reduces costs related to arrest and incarceration
Fewer crimes committed also would reduce court costs and lawyer fees
Initial drug rehab and addiction treatment is less costly than prison
Addiction treatment and recovery improve health overall, which then reduces healthcare costs in both the short- and long-term
Addiction treatment and recovery would reduce costs associated with lost work productivity, either from incarceration or drug-related injury and illness
Recovery would save resources spent on caretaking for children of offenders or addicts

Prisons are not equipped for rehabilitation.

The U.S. Department of Justice estimates that 15 percent to 20 percent of the United States’ 2 million prisoners have a mental illness. Unlike clinics and hospitals, however, the prison system was not built to address serious mental-health needs.

Psychologists and, to a lesser extent, psychiatrists do provide mental health care to prison inmates, and may provide helpful rehabilitative services. Such programs, however, are difficult for prison-based therapists to implement on top of their already heavy caseloads. There are also not enough mental-health professionals to address every need in U.S. prisons.

Rehab programs for inmates are also difficult to create and implement because of philosophical and priority differences. While psychology is focused on treating and rehabilitating patients, the current criminal justice system is focused on punishing offenders.

What does the research on addiction treatment show?

Research dating back to the 1970s has shown that the prison environment itself has a major effect on behavior and mental health. The Stanford Prison Experiment, published in 1973, demonstrated that a prison-like environment can bring out depressive or sadistic behavior in even psychologically healthy individuals. This alone suggests the benefits of rehabilitation over incarceration, especially for less serious offenses.

A more recent study suggests that sending just 10 percent of eligible offenders to community-based treatment programs instead of prison could save $4.8 billion. If 40 percent of eligible offenders were sent to the programs over prison, it would save $12.9 billion.

Researchers based their findings on a lifetime simulation model of a cohort of 1.14 million state prisoners. The model accounted for chronic substance abuse, estimated the lifetime benefits of treatment, and calculated costs related to policing, trial, and incarceration. The study was published in “Crime & Delinquency” in 2012.

Provide better addiction treatment with better solutions.

Whether you’re making the switch from paper to EHR or looking for a new EHR solution, BestNotes EHR and CRM software is designed with behavioral health and addiction treatment providers in mind. Talk to us today to find out more and request a free demo.

date:  Dec 10, 2018
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