[This post was originally published on 28th May 2021. It has been updated on 24th May 2024.]
A wide array of digital innovations has revolutionized healthcare in the last few years. From online appointment scheduling to patient-provider communication, digital tools have modernized and mobilized the chiropractic industry. A perfect example of a revolutionary innovation in the chiropractic space is SOAP notes with voice dictation. Today, SOAP note for chiropractors – an acronym for Subjective, Objective, Assessment, and Plan – is the most common method of documentation used by chiropractic providers to input daily notes into patients’ records. Different chiropractic practices use their unique SOAP note templates, but the idea is to record and share information in a universal, systematic, and easy-to-read format.
Chiropractic SOAP Notes and Voice Dictation
Healthcare providers are frustrated with time spent on patient encounter documentation and how it cuts into patient care. As the demand for more detailed documentation of every encounter is on the rise, speech recognition can improve and speed up patient encounter documentation.
In a survey conducted by KLAS, a healthcare IT research firm, it was found that 9 out of 10 healthcare clinics are planning to expand their use of speech recognition. Voice Dictation is a text-to-speech recognition technology that enables providers to save a substantial amount of documentation time and ensures the completeness of chiro SOAP notes. With timely completion of charting, chiropractic practices can submit claims on time, which can result in a higher reimbursement rate.
There are two types of speech recognition software
The front-end speech recognition tool requires the provider to speak into a microphone or headset attached to a PC. The provider must review everything and then sign off on the chiro SOAP notes. A back-end speech recognition software relies on the software’s capability to convert speech directly into text without initial oversight from the provider. However, proponents say front-end speech recognition tool like voice dictation is the most effective way to document patient visits. Voice dictation integrated with online chiropractic SOAP notes software allows providers to complete notes faster and create accurate documentation.
How to Dictate a SOAP Note
Dictating chiro SOAP notes in zHealth is a straightforward process that ensures creating quick soap notes for chiropractic accurate and efficient documentation of patient encounters. Follow these steps to effectively dictate your SOAP notes:
1. Access zHealth: Log in to the zHealth dashboard and navigate to the SOAP note section for the patient you are documenting.
2. Choose the SOAP Section: Select the appropriate section for the SOAP note you wish to dictate: Subjective, Objective, Assessment, or Plan.
3. Begin Dictation: Use the built-in dictation feature in zHealth’s chiropractic SOAP notes software. Start dictating by clicking on the record button inside the SOAP note tool. Talk at a conversational speed. To stop, click on the stop recording button again. You can use your Mac’s or PC’s internal microphone to dictate or use an external microphone attached to the system for accurate documentation.
4. Follow SOAP Format: Ensure your dictation follows the SOAP format:
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- Subjective: Patient history, symptoms, and complaints.
- Objective: Measurable findings, examination results, and diagnostic tests.
- Assessment: Diagnosis, prognosis, and differential diagnosis.
- Plan: Treatment plan, including medications, therapies, and follow-up instructions.
- Review and Edit: After dictating each section, review the transcribed text for accuracy and completeness.
Benefits of Voice Dictation in SOAP Notes or Charting
1. Voice dictation allows you to document SOAP notes in real-time. No need to stay after hours or work from home to complete your notes.
2. The voice dictation feature in online SOAP notes allows you to accurately dictate your patient encounters.
3. A study published in 2020 revealed that healthcare providers felt that speech recognition in documentation saves time, increases efficiency, and allows them to quickly document more relevant details.
4. Medical speech recognition increases documentation speed by 26%. You can take back control of your time and spend more time interacting with patients than documenting their visits.
5. Voice dictation in online SOAP notes for chiropractors can accurately translate your voice into a rich, detailed narrative that feeds directly into the EHR.
6. You can put the patient back at the center of care. Voice‑enabled patient documentation provides chiropractic providers with more time to observe, listen and interpret the patient’s problems.
Example of Chiropractic SOAP Note
You can dictate your SOAP note for each section like the example given below:
Subjective:
The patient presents with complaints of neck pain that began approximately two weeks ago on May 2nd 2024. He describes the pain as a dull ache located primarily on the right side of his neck, radiating to the right shoulder. The patient reports that the pain worsens with prolonged sitting and computer work. He denies any recent trauma or injury to the neck but notes increased stress at work. Additionally, he reports occasional headaches and stiffness in the neck upon waking in the morning. Pain is rated as 6/10 on the visual analog scale.
Objective:
On physical examination, tenderness is noted along the right cervical paraspinal muscles, particularly at C5-C6 level. Range of motion in the cervical spine is limited, with pain and stiffness noted during flexion, extension, and lateral rotation to the right. No signs of swelling, redness, or palpable masses are observed. Neurological examination reveals intact sensation and strength in the upper extremities, with no signs of radiculopathy.
Assessment:
1. Diagnosis revealed that there is cervical muscle strain with associated myofascial pain syndrome.
2. Contributing Factors are prolonged sitting, poor ergonomics, and increased stress.
3. Differential Diagnosis ruled out cervical disc herniation, cervical facet joint dysfunction, and cervical spondylosis.
Plan:
1. Initiated spinal manipulation targeting the cervical spine to restore proper joint mechanics and alleviate pain.
2. Performed myofascial release techniques and trigger point therapy to address muscular tightness and trigger points in the cervical paraspinal muscles.
3. Provided examples of home exercises focusing on cervical mobility, stretching, and strengthening of the neck and shoulder muscles.
4. Provided guidance on proper workstation ergonomics and posture modification techniques to reduce strain on the neck.
5. Discussed stress reduction strategies, relaxation techniques, and ergonomic breaks during prolonged computer work.
6. Scheduled a follow-up appointment in one week to assess treatment response, adjust the treatment plan as needed, and monitor progress.
This chiropractic soap notes example reflects the subjective and objective findings, assessment, and plan for the management of neck pain in a patient.
Choosing the Best Voice Dictation and SOAP Notes Software
The best-designed chiropractic software combines SOAP Notes and voice-based functions so you can create quick SOAP notes for a chiropractic patient. zHealth Software provides a fast, accurate, and responsive voice dictation feature in its chiropractic SOAP notes software with end‑to‑end security. zHealth’s voice dictation tool frees up your time from the keyboard and screen so you can spend more time with patients and improve quality of care outcomes.
To learn more about how to dictate a SOAP notes using zHealth and how it can help you document faster, better, and smarter, contact us here.
