The SOAP notes allow chiropractors to evaluate whether treatment is working and the progress of the patient. These notes are necessary for other patients who have similar injuries, and they are required by law in many states.
SOAP notes should be concise, clear and thorough. The patient’s injury/illness type, the date the injury or illness started, the test results, the progress observed and the treatment should be included. Knowing what to include and what not to in your soap notes, even with high-quality chiropractor software is important.
What should you include in your Chiropractic soap note?
Quality over Quantity
The chiropractic SOAP notes have four sections: Subjective, Objectives, Assessments, and Plans. Focus on the inclusion of crucial information in each section. Quantity and volume are only useful if the quality of the information is maintained. Your notes can be short, as long as all the relevant information is included.
Notes should include all relevant information about the patient, including injury, progress, plans, and treatment. It’s acceptable to have a lengthy soap note, as long as it is because the patient has a lot of information and not overly wordy.
What the patient says
You must only include certain things that the patient says in your notes. You must still record the pain or injury that is reported by the patient even if it does not seem to be related to what you initially treated. The records you keep can help with future diagnosis.
Chiropractic SOAP Notes: Key Areas
The key pillars in your report are the subjective, objective, assessment, and plan notes. Avoid writing statements in the subjective section without a patient’s evidence.
The objective section will quantify patient comments. Use the PART method to document this section. This includes pain, asymmetry and range of motion as well as tissue or tone changes. This approach will allow you to provide a comprehensive assessment of the patient’s current condition.
You basically give your opinion on the progress of the patient. Always record lab and imaging results. You should also highlight any changes to the diagnosis. This section is where you can include any pertinent information, which will serve as a reference for the next appointment.
The plan should include a section that outlines the treatment plan for the patient. The spinal manipulation treatment plan must always include the areas being adjusted. This segment should include any ancillary treatments, such as therapeutic ultrasound.
Improve Your SOAP Notes
Your SOAP notes will not only help you track and document a patient’s care and progress, but they can also protect you against hefty fines that may result from insurance audits and coding violations. If your practice is based on insurance, you must ensure that your notes match the charges submitted to third parties by the biller. Apply the tips above to improve your SOAP note taking skills. You can use chiropractic software that includes soap templates to stay up-to-date, access information quickly, and store it safely.
