Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The SOAP Methodology

Step 1 is to obtain a set of clinical records. Analyze them to determine where the provider documents the elements of SOAP. For example, where does this provider typically document a patient’s statement? Where does the provider document objective data such as physical assessments, diagnostic tests, and vital signs? Where does the provider communicate the patient’s assessment and ongoing adjustments? Finally, where does this provider document its current and ongoing plan of care?

Step 2 in the process is to understand whether the provider uses any transitional documents. Does the provider document any aspect of patient care in documents not contained within the master medical record file? For example, the term shadow chart is associated with files that are kept separately within another department. These types of records are usually generated secondary to some type of operational issue. In one hospital audited, the staff kept shadow charts because they were unable to retrieve necessary records from the main chart in a timely manner. A less altruistic provider was a dentist who kept two sets of records—one set of real records that contained what was actually done to the patients and a second so she could keep track of her communications with the payers.

Look at the document in Exhibit 21.1 and identify the elements of SOAP.

Exhibit 21.1 Illustration of a Nursing Record

The very structure of this form does not promote the communication of patient statements, ...