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At the risk of stirring up a hornets nest of debates on topics such as exactly where and when you should use a comma, as opposed to a semi-colon, or whether one should write “auto accident” or “auto collision”, when describing a car wreck, or whether one should follow the dictionary Usage Panel when deciding to write "totaled" or "totalled", when describing a wrecked car ( who are those Panel dudes, anyway?); I’m going to attempt to clarify what’s really important, and what’s not so important, in a Narrative Report and a Daily SOAP Note.

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This will be the first in a series of Report Writing Tips Newsletters that will attempt to shed some light on, and hopefully clear up, the morass of complexities, restrictions, rules, etc., etc., etc. of the sometimes confusing, but almost always unpleasant subject of writing Narrative Reports and Daily SOAP Notes.

Writing effective Narrative Reports and Daily SOAP Notes does come down to a few simple basic fundamental concepts, despite what any of a hundred insurance adjusters might tell you to the contrary.

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Voltaire, the 18th Century French philosopher once said, "If you are going to argue with me, define your terms."

In actual fact, it would be near impossible for you to maintain an argument with someone if you took time out to define the key words of what you are arguing about. For example, if two people arguing about their religious beliefs, actually took the time to fully define for each other and for themselves, what each meant by the term God, the argument would quickly cease to exist.

In other words, if someone tells you your Narrative Reports and SOAPs look canned or they all look the same, or they don't look enough alike, find out from that person how they define "canned", and get examples of what a "not canned" report would look like. Who are their sources? What yardstick are they using, in other words, to judge your reports. Get them to define their terms.

The fact is, they might be correct. But, until you get them to explain exactly what they're talking about, it will be difficult, at best, to determine if what they're saying has any actual value to you.

In the final analysis, the most important element in writing reports is simply this: Do they communicate? Can they be easily understood by the recipient. And do they fully describe what it is you are trying to describe, and in a manner that the recipient can easily digest and understand.

How each report compares to earlier reports; if they are "randomized;" or if they look completely different from one to the next, REALLY DOESN'T MATTER.

What really matters is that exact report you are writing RIGHT NOW. Is that report or note going to be fully understood by the recipient, in terms of what it is you are attempting to communicate.. And obviously, a key part of this particular type of communication is: are you giving them an adequate AMOUNT of information in the reports.

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Unless you're trying to baffle the insurance company with your genius, you need to keep it simple. That doesn't necessarily mean keeping it short. If an initial narrative needs to be 20 pages, to fully document what you did and what you propose to do and why, then make it 20 pages.

In fact, if describing how each Orthopedic and Neurologic test is performed, adds another 5 pages to your report, do it. A hard to please insurance adjuster may still complain about your reports, but he definitely won't kick back your claims for lack of data.

Avoid medical lingo as much as possible, unless you're using the report to send to the patient's primary physician. But, even then, are you sure the MD is going to know what a Kemp's Test is? Why take the chance? There's nothing like a hard to understand report to kill any future hopes of getting more referrals from that MD.

Also, if you write your reports from the viewpoint of the patient being able to understand it, then unless the patient is an Einstein, you can be fairly confident that most anyone you send the report to will be able to understand it. And, while you're at it, why not give your patient a copy of his or her initial report to accompany any patient education and/or report of findings you do with the them?

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The other part of this subject you'll have to deal with is the mechanical aspect of report writing. If the mechanics get in the way of what you are trying to communicate, then all is for naught.

So, if you're a hunt-and-peck typist, or you can't dictate because you clam up with stage fright whenever a microphone comes within two feet of your face, then you'll probably need a different system of writing your reports and notes.

In other words, your method of communicating needs to be as simple and understandable as your communications themselves.

In fact, if you are trying to document all of this by hand, you are probably finding that there aren’t enough hours in the day. And I'm sure you'd much rather be working with patients than messing with daily notes and/or narrative reports.

If you would like an easy, fast system, give us a call toll-free at 877-742-9215 and speak to one of my consultants.

Report Master Testimonials

If you are commited to sending high-quality, professional reports, chances are very good that you will never have a problem, stemming from documentation.

If you don't own Report Master yet, check out some of the Testimonials on our web site, to see what others are saying about the Report Master Software.

If you would like to have one of my consultants walk you through the Report Master Software Program, to see if Report Master will work in your office, click on the link below and sign up for a Free Live Demonstration of our system.

Report Master takes the work out of the Narrative and SOAP Note writing process, so you'll have more time to do the things you would rather be doing, and still maintain the necessary quality in your reports that others, and particularly you yourself demand.

So, relax and let Report Master write your reports for you.

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