A chiropractor’s SOAP notes entail the provided services and establish why a patient is receiving treatment. “SOAP” is abbreviated for headlines Subjective, Objective, Assessment, and Plan. Certain comments on related information should not be included in the notes because they require specific medical descriptions.
Common mistakes in recording soap notes include writing down the chiropractor’s thoughts on the diagnosis, rewriting the treatment plan, and making statements that lack supporting data. The SOAP notes must be filled out correctly. Accuracy of notes ensures an accurate depiction of the patient’s predicament.
Insurance reimbursement depends on whether treatment is medically necessary. By completing SOAP notes correctly, the patient’s well-being is secured, and treatment outcomes are more likely to be positive. Now that you know what not to disclose, continue reading to learn what to include in your chiropractic soap notes.
What are chiropractic soap notes?
A SOAP note is a plan that includes patient information for medical professionals. The goal is to provide concise, quality chiropractic soap notes outlining the patient’s condition, diagnosis, and treatment. The notes are specific, with each heading requiring details outlining symptoms and medical history. The notes should be between one and two pages.
The “S” in SOAP is “subjective.”
The “Subjective” portion describes the patient’s primary complaint. Chiropractic symptoms typically relate to neuromuscular pain or issues like back or neck pain. It is considered subjective because it relates to the patient’s experience.
When the patient has their initial visit, the medical professional will record the symptoms the patient describes and other information, including.
- when the pain started.
- pain severity.
- patient’s history.
- injury trauma.
- mechanism of the jury.
The initial take of the note is longer than those that come later because it consists of the patient’s medical history.
For follow-up visits, chiropractic soap notes will include the following.
- new symptoms.
- pain severity.
- how the pain has evolved.
- how the condition influences daily living.
The “O” in SOAP is “objective.”
Here, the chiropractor writes any measurements of patient data like weight, vital signs, and lab results. The chiropractor will record any findings from physical examinations. For chiropractic care, findings result from neurologic, orthopedic, and range of motion tests.
The “A” in SOAP is “assessment.”
Here, the chiropractor indicates the diagnosis, prognosis, and other diagnoses relevant to the condition. Based on the assessment, the chiropractor’s view of the patient’s progress is recorded. If a diagnosis isn’t clear, the chiropractic soap notes include a list of potential diagnoses.
The “P” in SOAP is “plan.”
This section includes the care plan to treat the patient and the work orders, specific reforms, and therapeutic interventions that are needed. The chiropractor will indicate any lifestyle modifications required by the patient.
Create accurate notes for the best patient outcomes.
The written obligations of the chiropractic soap notes are to provide clear information so that if a new medical professional was to take over, they could quickly determine what is needed. Study the note format to record your own with accuracy and efficiency.