Electronic Records

The market is aggressively focused on incorporating electronic records throughout the P-HCC. Providers have had a more significant emphasis on this subject since they typically generate records at the time a patient initiates a service. However, records can be initiated anywhere throughout the P-HCC. For example, an employer may generate healthcare records resulting from an employee-related injury. Nevertheless, standards and compliance initiatives are still heavily focused within the provider market. However, the emphasis should be on developing compliance and standards for electronic health information contemporaneously throughout the P-HCC, regardless of role.

To date, a greater emphasis has been placed on the initiative, security issues, and infrastructure. Development of content standards has yet to be addressed with any sort of substance. Therefore, with respect to audits and investigations, the SOAP methodology provides a common ground and methodology to interpret a variety of styles and forms of clinical documentation. Exhibit 21.12 provides an overview of the SOAP methodology.

Exhibit 21.12 SOAP Methodology Overview

Step 1: Obtain a copy of the provider’s standard set of medical records.
Step 2: Understand whether the provider uses any transitional documents.
Step 3: Identify any known issue to be investigated or simply audited.
Step 4: Create the SOAP grid for the audit.
Step 5: Apply SOAP analysis to each selected narrative entry.
Step ...

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