What to Include in Your Chiropractic Practice SOAP Notes

Highlights  

• Chiropractic SOAP notes keep your practice compliant and ensure top-notch patient care.

• SOAP notes are essential for cash-based and insurance-based chiropractic practices.

• Chiropractic SOAP notes provide a roadmap of care for your patients and help you align billing with the day’s treatments.

• A fully integrated chiropractic EHR practice management system like ChiroTouch allows you to complete SOAP notes quickly and efficiently and spend more time with your patients.

Chiropractic SOAP notes provide your practice with a structured approach to patient care. Keeping up with SOAP notes can be difficult if your practice uses outdated EHR software that doesn’t offer customizable macros and automatic syncing. ChiroTouch allows you to enter SOAP notes in seconds, so you stay compliant and provide excellent patient care.

What are SOAP Notes and Why Are They Important for Chiropractic Practices?

SOAP notes are a method of documentation used in the healthcare industry to document a patient’s diagnosis and treatment. The SOAP (Subjective, Objective, Assessment, and Plan) notes framework helps practitioners keep track of their patients’ progress during treatment. It also provides a detailed reference tool that providers can consult during future chiropractic sessions to adjust treatment plans or reevaluate diagnoses.

For chiropractors, maintaining SOAP notes is essential. SOAP notes keep you in compliance with reporting and licensing requirements. They provide documentation for third-party providers or boards of examiners who may ask to review the patient’s treatment information.

They also help you structure patient visits to achieve a high level of care that meets their needs. Using SOAP notes helps your patients feel heard and receive personalized treatment for their concerns.

Routine Office Visit SOAP Notes Must-Haves

To accurately complete SOAP notes for your chiropractic patients, you’ll want to follow the Subjective, Objective, Assessment, and Plan structure. Include the following information for each category to ensure complete, accurate notes.

Subjective

The subjective section of your SOAP notes includes the patient’s description of their chief complaint, the history of their current medical condition, and how it affects their activities of daily living (ADLs). This history includes information such as when the complaint started, where it is located, the duration of the complaint, the severity of pain, and whether the discomfort radiates to other parts of the body.

If the patient is returning for a follow-up visit, document these notes as changes since their last session, including pain scale ratings and same/better/worse self-assessments. Each of these should include a brief description of how the patient arrived at this opinion.

For example, the patient may report, “The pain is better than last time because I can sit longer without discomfort.”

Objective

The objective section of chiropractic SOAP notes helps quantify the patient’s personal comments. Include objective findings and evidence of changes since the last visit. Record evidence that shows whether the patient is the same, better, or worse since you last saw them.

Use the Pain, Asymmetry, Range of Motion, and Tissue/Tone changes (PART) documentation method indicated by the Centers for Medicare and Medicaid Services. This approach provides a thorough and objective assessment of your patient’s current state of health and mobility.

Assessment

The assessment portion of chiropractic SOAP notes lets you share your thoughts about your patient’s improvement or decline. You can also record your recommendations for future treatment outcomes, potential setbacks, or any other relevant assessments you’ve made. This is also the section to record lab or imaging results or changes in diagnosis.

Plan

The final section of chiropractic SOAP notes outlines a plan for treatment the patient receives during their visit. Chiropractic spinal manipulation documentation must include the regions of the spine you adjust.

You must also record ancillary treatments used, such as transcutaneous electrical nerve stimulation (TENS) or therapeutic ultrasound, including location, muscle groups, sets, reps, unit time, and/or total time. You should also record changes to the plan made on the visit and notate if you discharged the patient after the session.

SOAP Notes Protect You

In addition to documenting and tracking patient care and progress, SOAP notes can protect your practice from insurance audits and hefty fees due to violations of CPT coding procedures. If you run an insurance-based practice, your SOAP notes must align with the charges your chiropractic biller submits to third-party payers.

Your SOAP notes describe the services you provide and explain why a patient receives a particular treatment. This is essential for insurance because reimbursement depends on the treatment being medically necessary.

Keeping accurate and detailed SOAP notes ensures your treatment improves the patient’s well-being. It also provides documentation for third parties who rely on the information for payment and assessment.

ChiroTouch and SOAP Notes

To maintain accurate SOAP notes for your chiropractic practice, turn to a fully integrated chiropractic EHR practice management system. ChiroTouch is an industry leader in chiropractic software and provides you with several features to support easy, convenient SOAP note entry.

BulletTouch Macros

One of the most amazing features of ChiroTouch is the ability to customize SOAP notes and macros to the style that each practitioner wants.  All chiropractors are different and want to document in their own verbiage, and ChiroTouch allows that with BulletTouch macros.

BulletTouch macros are 100% customizable through the charting portion of the dashboard. With them, you can create a functional SOAP notes template that allows you to complete patient charts in as little as 15 seconds.

BulletTouch Macros also help you to standardize your practice’s patient notetaking so you can share custom templates with colleagues.

Easy To Access

Since ChiroTouch is cloud-based, patient SOAP notes are accessible from your desktop, laptop, or tablet. This allows providers to complete patient intake, exam, and assessment and create treatment plans from their iPads while the patient is in the room.

It also allows CAs to access patient information for billing and sending appointment reminders.

Auto SALT Feature

ChiroTouch’s auto SALT (same as last treatment) feature speeds up charting for patients returning for further treatment. It allows you to enter the same chart notes, diagnoses, treatment plan, and fees from the patient’s previous treatment session with a single click, so you can update their notes in a few seconds.

Coding Compliance

Accurate CPT codes are crucial for ensuring fast insurance processing to maintain your practice’s cash flow. Medicare has strict requirements for coding, and ChiroTouch SOAP note templates ensure that you are always CMS compliant.

ChiroTouch SOAP notes templates are designed to be audit proof by including evidence-based treatment effectiveness and medical necessity. They are also compliant with evaluation and management guidelines required by third-party payers.

Chiropractic SOAP Notes Made Easy With ChiroTouch

ChiroTouch’s completely integrated chiropractic EHR practice management software makes keeping up with SOAP notes easy for your practice. Our customizable macros and automated features allow you to complete chiropractic SOAP notes in seconds so you can spend more time with your patients.

Have a well-adjusted day!

Schedule a demo today to discover how ChiroTouch can elevate your patient care and documentation process by supporting convenient SOAP notes integration.