What Are Chiropractic SOAP Notes?

Highlights

• A chiropractic SOAP note contains the patient’s subjective complaints, objective findings from the physical examination, a chiropractic assessment and diagnosis, and a detailed treatment plan.
• SOAP stands for Subjective, Objective, Assessment, and Plan.
• Chiropractic SOAP notes provide a roadmap of care for your patients and help you align billing with the day’s treatments.
• Effective chiropractic EHR software can simplify the process of documenting SOAP notes, making a once tedious task easy.

Chiropractic SOAP notes are critical to your daily patient care as they help you document patient concerns and lay out a diagnosis and treatment plan. SOAP notes also benefit your office team as they file insurance claims since EHR software can link SOAP macros to CPT billing codes.

Here’s what SOAP notes are and how chiropractic practice management software can simplify note-taking.

What Are SOAP Notes?

SOAP notes are a standardized system for documenting patient encounters in healthcare, including chiropractic care.

SOAP notes support accurate chiropractic coding and billing for practical office management purposes.

In the 1960s, Dr. Lawrence Weed of the University of Vermont invented the notes, and it didn’t take long for them to become a widespread practice in the medical profession.

The acronym “SOAP” stands for:

• Subjective: This section captures the patient’s perspective. It includes information such as the patient’s chief complaint, medical history, and current symptoms.
• Objective: This section focuses on the chiropractor’s observations and findings during the physical examination. It may include details about the patient’s posture, range of motion, reflexes, and any abnormalities detected.
• Assessment: This section is where the chiropractor analyzes the information gathered in the subjective and objective sections to form a diagnosis or clinical impression.
• Plan: This section outlines the proposed treatment plan, including specific chiropractic adjustments, therapeutic exercises, or other interventions. It may also include a timeline for treatment and any necessary follow-up appointments.

Why Are SOAP Notes Important in Chiropractic Care?

SOAP notes serve several crucial purposes in chiropractic practice:

• Legal documentation: They provide a detailed record of the patient’s condition, treatment plan, and progress. This documentation can be essential in legal proceedings, such as malpractice claims.
• Communication: SOAP notes facilitate effective communication between the chiropractor and other healthcare providers involved in the patient’s care.
• Insurance claims: Accurate and complete SOAP notes are necessary for submitting accurate insurance claims.
• Patient care: Well-documented SOAP notes can help ensure the patient receives appropriate and timely care.
• Quality assurance: By reviewing SOAP notes, chiropractors can identify patterns in patient presentations and treatment outcomes, leading to improvements in care.

By understanding the components of SOAP notes, chiropractors can effectively document patient encounters, improve communication with colleagues, and provide high-quality care.

Subjective Objective Assessment Plan (SOAP)

It’s easiest to understand the SOAP notes concept when going over each component of this documentation.

Subjective

This is the patient’s chief complaint. In chiropractic, that’s likely back pain, neck pain, or some other neuromuscular issue. It’s subjective, as it conveys the patient’s experience of their condition.On the initial visit, the doctor records the patient’s symptoms, when the pain began, and the pain severity. It also considers the patient’s medical history. If trauma was involved, the patient is asked to explain the mechanism of injury.

The first subjective note for a patient is generally much longer, as it contains the history elements. Subsequent subjective notes on follow-up visits should include any changes in symptoms or new symptoms, the current level of pain, and how the pain has changed since the last patient visit. It also documents how the problem affects a patient’s daily activities and any functional improvements.

Objective

This part of SOAP includes the chiropractor’s measurable data of the patient, such as weight and vital signs. The results of any laboratory testing or imaging are part of this process, along with findings from the chiropractor’s physical examination of the patient.

The exam note includes all testing performed, such as orthopedic, neurological, and range of motion. The daily chiropractic notes include items such as asymmetry, palpatory pain, tissue changes, and joint fixation.

Assessment

The assessment records what the doctor learns from the patient’s information and the examination performed. The assessment includes the diagnosis and prognosis and may also involve a differential diagnosis.

When the diagnosis is unclear, the doctor should include possible diagnoses listed in order of most to least probable. This component includes a chiropractor’s assessment of the patient’s progress.

Plan

The plan communicates what the chiropractor will do to address and treat the patient’s condition. It includes any lab work ordered, therapeutic treatment and exercises, the expected duration and frequency of care, and any referrals needed.

It also includes notes when a patient requires any type of lifestyle modification. During each patient visit, the chiropractor should note any adjustments or other services provided.

Keep in mind that SOAP notes must prove clear and intelligible to a third party. If another doctor had to take over your patient’s treatments, could they easily get up to speed by reading your SOAP notes on the patient and continue treatment? If the answer to this question is a resounding, “Yes!” your documentation is clear and effective.

How to Use Chiropractic SOAP Notes

The best SOAP notes are geared toward quality rather than quantity. While thorough notes are crucial, the most important aspect is to determine how to address a patient’s complaint by way of diagnosis and treatment.

If SOAP notes don’t include the essential details, such as the exact type of pain and location, it is difficult, if not impossible, to assess treatment efficacy.

Detailed chiropractic SOAP notes provide you with thorough documentation. The lack of extensive documentation can really hurt you if you are ever sued. On the other hand, detailed SOAP notes can prove the plaintiff doesn’t have a case.

SOAP notes also help keep you compliant. If audited, they will prove you followed the proper procedures and billed patients correctly.

Chiropractic SOAP Notes and Medicare

While SOAP notes are crucial for any patient, they are especially critical for those patients covered by Medicare. The rules for chiropractic SOAP notes for Medicare patients are stringent. Medicare’s specific guidelines require that records document symptoms bearing a direct relationship to subluxation levels.

This means if a chiropractor doesn’t correctly document a subluxation, referring to the pain and tenderness, misalignment or asymmetry, and range of motion abnormalities, Medicare may reject the claim.

ChiroTouch EHR Software and SOAP Notes

Even under the best of circumstances, SOAP note documentation is a tedious task. The right chiropractic EHR system makes creating your SOAP notes a breeze and increases the efficiency of your practice.

A good chiropractic EHR system saves you time and money; it lets you spend more of your day with your patients rather than dealing with documentation.

SOAP notes really start with the initial patient appointment, so ChiroTouch chiropractic practice management software is with you for every aspect of the patient care process.

ChiroTouch’s macros allow you to complete your soap notes in 15 seconds. The macro is used in conjunction with the patient intake tool, so you can automatically send your patient’s intake response to the subjective section of your soap note.