SOAP notes enable chiropractors to assess whether the treatment works and the patients progress. The notes are also necessary when handling other patients with similar injuries and are a legal requirement in many states.
SOAP notes need to be clear, thorough, and concise. They should include the patient’s type of injury/illness, when the injury occurred or when the illness began, test results, an assessment, progress observed, and treatment. Even with quality chiropractor software, knowing what to and not to include in your soap notes is essential.
Let’s look at the key factors to include and what to leave out in your Chiropractic soap notes.
Table of Contents
Chiropractic SOAP notes are in four key sections, Subjective, Objective, Assessment, and Plans. Throughout these sections, focus on including crucial information. The quantity and volume of information are only valuable when quality is maintained. It’s okay for your notes to be brief, provided all relevant information has been included.
The notes should capture every aspect of the patient’s injury, progress, treatment, and plans. A lengthy soap note is acceptable, provided it’s because all the relevant factors were bulky and not just over wordiness and minor issues.
Only some things the patient says must appear on your chiropractic soap notes. However, you must record any pain or injury reported by the patient, even when it doesn’t appear to relate to what you were treated for initially. Some injuries are related, and the records you make can be helpful with your future diagnoses.
The subjective, Objective, Assessment, and Plan notes are the key pillars of your report. In the subjective section, avoid writing any statement without accompanying evidence from the patient.
The objective section of chiropractic soap notes will quantify the patient’s comments. In this segment, try using the PART documentation method, which includes pain, asymmetry, range of motion, and tissue or tonal changes. The approach will help you provide a thorough assessment of their current state.
In the assessment section, you basically share your thoughts on the patient’s progress. Remember to always record imaging and lab results. It’s also important to highlight any changes in diagnosis at this level. Place any relevant information in this section, as it will be a crucial reference on their next appointment.
In the final section, the plan should outline the patient’s treatment plan. Any spinal manipulation treatment plan should always identify the regions being adjusted on the spine. Any ancillary treatment like therapeutic ultrasound implemented should be indicated in this segment.
Apart from tracking and documenting a patient’s progress and care, your SOAP notes protect you from hefty fees, which result after violating coding procedures and insurance audits. When your practice is insurance based, your notes must align with the charges the biller submits to third parties. Practice your SOAP note-taking skills by applying the above tips. Use chiropractic software with soap templates to help you stay updated, quickly access, and safely store information.
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