If you are in the medical industry, you are probably familiar with SOAP notes. SOAP (Subjective, Objective, Assessment, Plan) is a note-taking format in the medical practice-chiropractic included. Chiropractic SOAP notes help with a structured patient care approach.
Keeping up with SOAP notes can be challenging, especially if working with outdated software that lacks automatic syncing and customizable macros.
Here is all you need to know about SOAP notes for chiropractors and their benefits.
What Are SOAP Notes For Chiropractors?
SOAP notes for Chiropractors are a documentation method in the medical field for patient diagnosis and treatment. The framework helps chiropractors track their patients’ treatment progress and provides a reference for future sessions to adjust or re-evaluate a treatment plan or diagnosis respectively.
Writing SOAP notes require the incorporation of all four acronyms as follows:
1. The Subjective Section
This section contains details the patients give you about their condition. You should start by capturing the patient’s main issue, whether back or neck pain. In an initial subjective note, include the patient’s symptoms, when the pain started, severity, conditions that worsen or improve the pain, factors contributing to the pain, and medical history.
If you have a follow-up patient, document the notes as changes and capture the pain scale ratings and self-assessments. The ratings and assessments should briefly describe how the patient settled for the opinion. Also, include new symptoms, notable changes to existing symptoms, deterioration or improvements since the last appointment, and effective and non-effective treatments and therapies.
2. The Objective Section
The objective section quantifies the patient’s comments. You can include the evidence of change from a previous visit using the PART documentation method by the Centers for Medicare and Medicaid Services.
3. The Assessment Section
The Assessment portion lets you share your thoughts on your patient’s decline or improvement. This section also allows you to capture recommendations for treatment outcomes and potential setbacks. You can record the results in this section if the patient assessment requires imaging and lab tests.
4. The Plan Section
The plan portion of the SOAP notes for chiropractors is the final step, outlining the treatment plan for the patient. In this section, record ancillary treatments and therapeutic ultrasound, capturing the muscle groups, location, sets, reps, and time. Also, capture changes you make to the plan, including discharges after the session.
Benefits Of SOAP Notes Software
SOAP note software for chiropractors helps in the following ways:
- Simplify accurate coding and billing for your services
- Helps in tracking patient’s progress
- Other medical administrative staff and healthcare professionals can easily understand
- It enables you to remain compliant in case of audits as you can prove you followed procedures correctly
- Serves as evidence in a medical malpractice claim
- Offers the specificity required by Medicare and other insurance providers
Consider SOAP Notes For Efficient Chiropractic Practice
SOAP notes gear towards quality rather than quantity. The main aspect of using notes is establishing how to address a patient’s complaint through diagnosis and treatment. A thorough SOAP note capturing all essential details will make assessing treatment efficacy possible. With this efficiency, you will be safe if a patient ever sues you for malpractice, as you can use your SOAP notes to prove your case.
