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 an EHR equipped with SOAP note creation is basically essential.

The best-designed EHRs 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 SOAP note templates based on different patient types 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 SOAP notes software can help you revolutionize your documentation system.

Step 1: Subjective

When a patient checks in for his or her appointment, zHealthEHR’s chiropractic SOAP note 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 note, you can input or edit additional information and details that the patient did not include in the sign-in forms. From this information, zHealthEHR automatically generates a clear “Subjective Findings” report.

Step 2: Objective

This is one of the objective SOAP note examples available in zHealth 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.

Step 3: Assessment

Next, you can complete the Assessment section 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, zHealthEHR 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

To finish up your SOAP note, enter the prescribed treatment plan for the patient in Plan. Gone are the days of worrying about detail and accuracy—zHealthEHR’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!