There are various ways to write a chiropractic SOAP note, but following a clear format can allow you to boost revenue in your chiropractic business, by increasing clinical outcomes and attracting more patients. To simplify things for you, we have compiled the four essential components that you must include in SOAP notes.
In this first section of the SOAP note, you must include subjective observations about the patient. As a result, you should be including information that is exclusive to the patient and that is unique to their situation, and doing so will help establish where to progress forward with treatment. Subjective information includes the history of the patient, the patient’s experience and point of view concerning their symptoms and onset, as well as their pain levels. The patient should be able to identify when this pain worsens or improves, and essentially, all information concerning their condition through their perspective. In some cases, interviews of family members or friends can be conducted to gather more subjective details.
For objective information, you must only note what is fact, and what can be scientifically deduced. Other healthcare professionals should be able to note the same findings, and there is no interpretation of the content whatsoever. This includes any vital testing, such as blood tests, blood pressure, oxygen levels, weight, and any scans and charts. It is all objective medical information that does not rely on the patient’s personal experience.
Using the subjective and objective observations, the assessment notes the diagnosis or prognosis of the current issue presented. If the chiropractor is unsure, then they must list all possibilities in order of probability to help identify what the issue could be. This is a broad assessment, and does consider the patient perspective to identify how likely they are to recover given their current progress, and what aspects could hinder recovery and improvement.
At the conclusion of the note, the chiropractor must note a plan for the patient. After all, the patient is being seen to improve, and so you must evaluate what is best for their next steps. It is curating a plan of action, and the plan should be very specific in detail. It is unacceptable to create generic plans, as it needs to be tailored to the patient’s needs. This means you should consider the current treatment, what can be done next, any further testing, how long this may take, referrals or further support needed, and frame this information within a specific time span.