[This post was originally published on 2nd Sep 2020. It has been updated on 24th May 2024]

The Subjective, Objective, Assessment, and Plan (SOAP) note is the most common method of documentation used for patients’ medical records. SOAP note templates enable healthcare providers to record and share information in a systematic, easy-to-read format. SOAP notes for chiropractors are so universal that using a chiropractic software equipped with SOAP note creation is basically essential.

The best-designed chiropractic software combine automated and manual functions to create note-taking capabilities that allow for pinpoint accuracy and rapid data entry—which are especially important for chiropractors, given the demand for specificity when detailing a patient’s physical ailments.

With zHealth Software, you get customized chiropractic SOAP Note templates to digitally create patient encounters and improve the quality and continuity of patient care. At zHealth, we transform your paper notes to customized chiropractic SOAP notes.

Our team can even create chiro SOAP notes based on different patient types (such as Cash, Insurance, PI, WC) and your unique requirements. Our digital SOAP notes include everything from natural fill-in-the-blank fields to shortcuts that allow you to input data with just a few clicks. With our voice dictation feature in comprehensive SOAP notes, you can dictate your notes faster and save time, streamline the input of information, and complete documentation faster.

Here’s how zHealth’s chiropractic SOAP notes software can help you revolutionize your documentation system.

Step 1: Subjective

The Subjection section of chiropractic notes captures everything a chiropractic patient shares about their complaint, along with their medical history and the review of intake forms. It is subjective as it conveys the patient’s personal experience of their condition. Common complaints include neck pain, back pain, and other neuromuscular issues. When documenting a new patient’s pain history or a new complaint, consider the following areas:

Mechanism of Injury: Detail how the symptoms began. If the patient denies any trauma, inquire about any new or repetitive activities at work or home.

Onset: The chiropractic notes should record the exact date of injury using day/month/year format, rather than vague terms like “last Tuesday.” If the patient cannot provide a specific date, note “insidious onset” with an approximate timeframe such as days, weeks, months, or years ago.

Palliative/Provocative Factors: Identify what alleviates (palliative) or exacerbates (provocative) the symptoms. This might include icing, heat, bending, sleeping, or specific movements.

Quality: Document the patient’s description of the pain. Common descriptors include achy, crampy, nagging, or throbbing.

Radiation or Referral: Note if the pain radiates or remains localized. If there is no radiation, record “patient denies radiation or referral of symptoms” or “symptoms remain local.”

Severity: Use a severity scale, such as “0-4” or “0-10,” along with a pain diagram or visual analog scale.

Temporal Factors: Include details such as:

• Is the chief complaint worse in the morning or evening?
• Is the pain constant or intermittent?
• Is it worse before or after specific activities?
• Has the pain worsened since onset?
• Is the pain associated with mealtimes, seasonal changes, or the menstrual cycle?

Unrelated Symptoms: Note any associated symptoms, such as headaches, or other symptoms that may seem unrelated.

The first subjective note for a patient is typically more comprehensive, as it includes their medical history. Follow-up SOAP notes chiropractic documentation should include any changes or new symptoms, the current level of pain, how the pain has evolved since the last visit, and how the problem affects the patient’s daily activities and any functional improvements.

When a patient checks in for his or her appointment, zHealth’s chiropractic SOAP notes software populates its comprehensive SOAP note template with information from the outcome assessment (OA) and intake forms that the patient fills as a part of the sign-in process.

In the Subjective portion of the SOAP notes for a chiropractic patients, you can input or edit additional information and details that the patient did not include in the intake forms. From this information, zHealth automatically generates a clear “Subjective Findings” report.

Step 2: Objective

This is one of the objective SOAP note examples available in zHealth chiropractor SOAP notes software. You can customize the objective part based on your patient types and specific needs. In this Objective SOAP note template, you can populate the SOAP note with objective findings, which are formatted in live-time into a summary.

For new patients, you can go to the Exam section and input results from a variety of physical examinations. The information is then organized into a clear “Exam Findings” report in your chiro SOAP notes.

Step 3: Assessment

Next, you can complete the Assessment section of your SOAP notes chiropractic documentation by adding the prognosis, patient statements, provider statements, and more. You can also detail the status of patient compliance to clearly identify areas for improvement and follow-up with patients more effectively.

For returning patients, zHealth integrates information from previous visits into the SOAP note template. In one click, providers can copy the assessment from the previous visit to expedite the documentation process.

Step 4: Plan

The Plan is all about what you will do to help the patient feel better. It’s like making a roadmap for treatment. Here’s what it can include:

Lab Work: If needed, you might have to order some tests to learn more about the problem.

Treatments and Exercises: You will decide on the best ways to help, like therapy and exercises.

How Long and How Often: You need to figure out how long the treatment will take and how often the patient needs to come in.

Referrals: If necessary, you might send the patient to see other specialists.

Lifestyle Changes: Sometimes, small changes in daily habits can make a big difference.

Nutrition Tips: Eating right can play a big role in feeling better, so we might give some advice on that.

Timeline: You will set a timeline for when we’ll start everything.

Methods: You’ll decide on the best techniques and adjustments for the patient.

When creating a detailed Plan, you don’t have to worry about accuracy because zHealth’s SOAP note templates include preset templates for different treatment types such as Physical Medicines, Personal Injury, and Therapeutic Exercises, ensuring that each action item you add is automatically categorized. All of the instructions are summarized in the “Treatment Plan” at the bottom of the page.

Review and Billing

After you have completed a SOAP note, you can add miscellaneous notes in the Additional tab and proceed to billing and claim submission. The Invoice tab allows you to quickly generate statements with the power of zHealth’s automated health insurance billing system. Finally, go to Review & Sign to view your clean, comprehensive SOAP note!

Conclusion

zHealth chiropractor SOAP notes software makes creating SOAP notes easy for chiropractors. With this software, you can quickly and efficiently document their patients’ information, examination findings, assessments, and treatment plans. This helps chiropractors provide better care for their patients by ensuring accurate and organized documentation of their health status and treatment progress.

You can customize your own SOAP notes by using zHealth’s Self-Service SOAP Notes Builder or use the templates from our library of chiropractic SOAP notes templates. By streamlining the SOAP note creation process, zHealth software allows chiropractors to focus more on their patients and less on paperwork, ultimately leading to improved patient outcomes and satisfaction.