10 Quick Tips for Chiropractors Writing SOAP Notes

Do chiropractors use SOAP notes?

Healthcare providers are required to document their clients' treatment and any progress observed as part of their health record management. Certain information needs to be included in these notes, and different formatting structures, including SOAP, have been created to assist practitioners in this process.

SOAP is a method for documenting patient information. It stands for Subjective, Objective, Assessment, and Plan. "Subjective" includes what the patient tells the provider, "Objective" includes measurable data, "Assessment" is the healthcare provider's diagnosis or opinion, and "Plan" outlines the treatment or next steps for the patient. This method helps keep records organized and clear.

All health practitioners must create organized clinical notes. It is a medical necessity, and chiropractors are no exception. SOAP notes help inform chiropractors of whether their treatment methods work and are valuable for documenting progress. Chiropractors can also use their SOAP notes as a reference point for patients who experience similar injuries to improve another patient's condition.

They are also used in certain legal cases where correct procedure and patient quality of care need to be proved. Writing effective and thorough SOAP notes will significantly help patients receive the treatment they need while protecting the chiropractor against potential lawsuits and other challenges. Various tools and techniques can assist with the process of creating SOAP notes, and some of these resources, including free chiropractic soap note templates and descriptions, are provided below. 

What are SOAP notes in chiropractic practice?

As mentioned above, these notes involve four sections: objective findings, subjective information, assessment, and plan. To consolidate your understanding and illustrate precisely what SOAP notes for chiropractors look like, here is what you should include in your documentation in the context of chiropractic care:

Subjective (S): The specific injury/pain experienced (e.g., neck pain) and when the patient says they first noticed it. Detail how painful the injury is and whether the patient has tried any treatments themselves.

Objective (O): Results of inspections of the area of interest; test results including orthopedic tests and pain assessments. For example, you may include physical examination findings like noting "forward head posture observed."

Assessment (A): The primary diagnosis and prognosis of the injury, as well as any progress, are noted. For example, following treatment, the patient has a sub-acute sprain, an improvement from the acute sprain identified in the last session.

Plan (P): Document any referrals that the patient needs, when improvements and progress can be expected, and when to have another session. Also, discuss changes to general lifestyle, for example, encouraging the patient to sit in a supportive chair while at work. Reviewing your SOAP notes documentation allows you to make appropriate chiropractic adjustments to the treatment plan.

10 effective tips on writing chiropractic SOAP notes

The process of documenting practical SOAP notes can be both daunting and time-consuming. To help you write the best chiropractic SOAP notes possible, we have curated some helpful tips:

1. The sooner, the better: SOAP notes are critical to every patient encounter. To eliminate the possibility of falling behind on documentation, you should try to write your SOAP notes after each session or, at the very latest, at the end of each day. 
2. Don't underestimate documentation: Although it may seem that spending time writing good SOAP notes prevents you from seeing more patients or doing other work, in truth, part of the role of a practitioner is keeping up-to-date, accurate documents. 
3. Focus on quality, not quantity: The essential part of every piece of documentation is the quality of the information you include. SOAP notes can be brief, but this should be due to removing vague wording rather than failure to include relevant information. The notes need to contain all details relating to the patient's symptoms, pain description, injury, treatment, progress, and plans. 
4. Be careful with templates: Although templates can give you, especially those new to the practice, a good idea of the information that can be included within SOAP notes, they can also be problematic. Many chiropractic SOAP note templates will consist of tests and assessments irrelevant to treating the specific injury. It may be better to adjust these templates so that documented information solely applies to the patient. 
5. Ensure accessibility: After writing SOAP notes, you must organize their documents to be easily accessed. An online, HIPAA-compliant system is one of the most effective ways to store SOAP notes.
6. Secure storage: As crucial as accessibility, you must store SOAP notes to safely guarantee patient privacy. 
7. Plan treatment: The final section of writing SOAP notes requires you to detail the patient's clinical impression and treatment plan. You should include information about the healing period for the injury and when the patient should book another appointment - likely, they will not know. 
8. Make it legible: Although it may seem obvious, chiropractic notes need to be legible as they are often read by people other than the practitioner who wrote them. If you have messy handwriting, convert it to writing your SOAP notes online. 
9. Listen to the patient: Record any injuries or pain that the patient says they are feeling, even if it seems unrelated to their present illness. Injuries may be related, and these records can help with future diagnoses.
10. Be clear with documentation: This rule helps you ensure that your SOAP notes are thorough and clear. It asks, if you were no longer available, would another chiropractor be able to understand the patient's injury, treatment, and progress just by reading your notes? If the answer is yes, then the documentation is considered effective.

Using a chiropractic SOAP notes template will help you improve patient care. Check out our SOAP Notes for Chiropractic Template with example for your reference.

Final thoughts

Writing effective SOAP notes is a critical aspect of effective and accurate documentation for chiropractors. SOAP notes need to be concise, clear, and thorough. They should include the patient's injury, when the injury began, test and assessment results, treatments, and any progress that has been observed. 

Following a chiropractic SOAP note template or example can help you learn about the various aspects of chiropractic sessions that should be documented. SOAP notes allow you to determine how much your patients have progressed and whether their treatment is working. These documents can be used as references for other patients with similar injuries and are often required by Medicare and legal situations.

Improve your chiropractic documentation. Try Carepatron for free today!