“If it’s not in writing, then it didn’t happen.” This means if you didn’t create accurate and complete chiro SOAP notes, insurance companies won’t consider your claims and may deny them altogether.

When it comes to insurance industries, there is a golden metric – clean claims are paid first, which means the claim:

• Was never rejected by the insurer
• Did not have a preventable denial
• Was not filed more than once
• Had no documentation errors

That’s why the way you create SOAP notes in your chiropractic practice has a huge impact on your revenue. The acceptance or rejection of your claims hinges on the quality of the chiropractic notes you generate and oversee. Notably, the most prevalent causes of claim denials are intertwined with patient documentation. This accentuates the importance of utilizing the best chiropractic SOAP notes software to streamline processes and enhance the likelihood of successful claims. Some of the issues related to patient documentation include:

• Incomplete documentation
• No documentation for the date of service
• Too many abbreviations that are hard to understand
• Documentation does not support the billing code
• Documentation does not demonstrate medical necessity
• The patient’s note does not demonstrate progress

“SOAP notes for chiropractors have been in use in chiropractic now for about the last 20 years, but we still have a number of practitioners who don’t use them properly. “People often say that it takes too much time and takes away from seeing patients and that they don’t get paid that much to do documentation,” says Tony Hamm, DC, past president of the American Chiropractic Association (ACA), who practices in Goldsboro, N.C.

What makes good chiro SOAP notes

An effective chiropractic SOAP note (Subjective, Objective, Assessment, Plan) requires attention to detail in each category. In the Subjective section, gather comprehensive patient history and complaints, delving into their concerns and pain points. In the Objective part, outline thorough examination findings, encompassing physical tests, diagnostic imaging, and palpation results. The Assessment stage demands a precise evaluation of the patient’s condition, incorporating diagnostic insights and potential underlying issues. Finally, in the Plan segment, articulate a comprehensive roadmap, incorporating recommended treatments, adjustments, therapeutic exercises, and follow-up appointments. Striving for thoroughness in each category guarantees that your chiropractic SOAP notes are a well-rounded and informative record of your patient’s journey toward optimal health. Let’s check out what good SOAP notes for chiropractors look like.

1. Subjective

The Subjective section should include whatever a chiropractic patient tells you about their complaint, as well as patient history and the review of intake forms. Having an integrated digital intake solution and SOAP notes chiropractic software allows you to get patient history and other subjective details automatically into the Subjective section of your notes. Other areas to consider when describing a pain history for a new patient/complaint are:

• Mechanism of Injury
• Severity
• Quality of pain
• Onset
• Radiation
• Scale Temporal Factors
• Unrelated symptoms

2. Objective

The Objective part of chiropractic notes should include the chiropractor’s measurable findings and data of the patient, including:

• Neurological tests
• Orthopedic tests
• Inspections of the area of chief complaint
• Palpation of soft tissues
• Subluxation/intersegmental dysfunction findings
• Imaging studies
• Outcomes assessments scores

Use zHealth’s quick SOAP notes chiropractic software that allows you to input these findings quickly with just a few clicks. What sets us apart is our commitment to tailoring SOAP notes to align with your unique treatment techniques and specific requirements. Our innovative Self-Service SOAP Notes Builder (SSSNB) empowers you to create personalized SOAP notes from scratch by simply dragging and dropping elements or utilizing sample templates, allowing you to design custom SOAP notes that perfectly fit your practice’s needs.

3. Assessment

The Assessment takes into account what the chiropractor learns from the patient’s information and the examination performed. It includes the diagnosis and prognosis, and may also involve a differential diagnosis. This section also includes a chiropractor’s assessment of the patient’s progress.

4. Plan

The Plan section of chiropractic notes should communicate what the chiropractor will do to address and treat the patient’s condition. This plan section can include things like:

• Therapeutic treatment and exercises
• Expected duration and frequency of care
• Lifestyle modifications
• Nutritional advice
• Timeline for implementation

HIPAA Compliance in Terms of Patient Notes

There are some regulations related to patient records defined by HIPAA. These laws underscore the obligation of medical and healthcare facilities, including chiropractic practices, to establish “formal documented procedures” tailored to their operations. This meticulous approach guarantees the safeguarding of patients’ confidential health data. Ensuring HIPAA compliance within chiropractic practices involves incorporating these crucial considerations, especially when employing chiropractic notes software to streamline and fortify record-keeping processes. It is necessary to ensure the privacy of your patient’s health information. So, you must keep these points in mind to become HIPAA compliant:

• HIPAA is all about how you protect your patients’ rights to privacy and the security of their information.
• Having HIPAA-compliant chiropractic software is important, but your practice must fulfill all HIPAA requirements.
• It does not matter whether you are a cash-only practice or don’t file electronic claims, you do need to fulfill your responsibility for the privacy portion of HIPAA.
• Your practice must document a list of the HIPAA requirements and how your office complies with those requirements.

To better understand the importance of HIPAA in patient privacy and why every care provider should follow HIPAA requirements, check out the Doe v. Medlantic Health Care Group, Inc case shared below:

The patient, a plaintiff in this case, was awarded $250,000 by the hospital for disclosing his HIV status. In this case, the patient visited the hospital with the hospital’s receptionist, who was also his co-worker. When the patient came back to his work, he found out his co-workers know about the fact that he had AIDS. The patient then sued the hospital and the co-worker claiming invasion of privacy and breach of a confidential relationship. The jury, in this case, found that the hospital was negligent and permitted access to confidential patient information. The jury asked the hospital to pay the patient $250,000 as compensation.

In chiropractic offices, the challenges with protecting patient information are not as significant as in other areas of healthcare sectors. However, the number of varieties of patients seeking chiropractic treatment is changing and it changes the dynamics of the relationship between chiropractors and their patients. This may create different issues in terms of patient relationships and their health information, which were not there a few decades ago. So, staying compliant with HIPAA when it comes to managing online SOAP notes is more important now than ever before. With patient notes software, you can also share access to past notes with patients with one click, thus helping you share health information with the patients as required by regulators.

Challenges of SOAP Notes Documentation 

Chiropractic SOAP (Subjective, Objective, Assessment, and Plan) notes are like a structured framework for keeping a track on how a patient is doing as they go through treatment. However, creating SOAP notes can be a challenging aspect for chiropractors, and several pain points can arise in the process:

• Time-Consuming Documentation

Creating SOAP notes using legacy or traditional systems is time-consuming and hinders the chiropractor’s ability to provide quality time to the patient.

• Inconsistency in Documentation

Without standardized templates or chiro SOAP notes software, there’s a risk of inconsistencies in the way chiropractors document patient information.

• Limited Customization Options

Manual methods or legacy systems lack the flexibility to adapt SOAP note templates to the specific needs of individual chiropractors or practices.

• Risk of Information Loss

Paper-based notes or non-integrated chiropractic soap notes software may pose a risk of loss or damage to patient records.

• Compliance Concerns

Keeping up with evolving healthcare regulations and compliance standards can be challenging. Non-integrated systems may result in difficulties synchronizing patient information with other practice management tools.

Challenges with Paper SOAP Notes

• Handwritten patient SOAP notes could be accessed by an unauthorized third party. With online SOAP notes, you get peace of mind, avoid dangerous medical mistakes, and prevent security breaches.
• Filling out a detailed paper SOAP note takes time. Using online chiropractic notes software note means you get more time to spend with patients and provide quality care.
• Managing paper files are expensive. Using paper patient records may be costing your practice thousands of dollars annually. In general, it costs about $25,000 to fill a four-drawer cabinet and $2,000 annually to maintain those paper files. Start using chiropractic notes software to save money in the long run.
• Another problem that arises with paper notes is the chance of misfiling a record. Misfiling patients’ health records can have negative effects on your practice. You may not be able to produce the patient records when you will be requested for audit review. Your claim may be rejected because of a lack of proper documents.
• Paper patient notes come with the need to pay for the storage space, personnel to manage, file, and access records, and a designated space just for these activities. With chiropractic notes software, all your patient notes stay in one place that you can access anytime, from a desktop, laptop, or tablet device.

Why Switch to Digital SOAP Notes

1. You need digital SOAP notes for chiropractors to organize patient records faster and more efficiently. You can reduce at least 90 percent of the time spent managing paper notes with chiropractic SOAP notes software.

2. Having your chiro SOAP notes accessible at the click of a button will allow you to better serve patients when they visit your practice.

3. Digital SOAP notes for chiropractors significantly reduce the time and expense associated with paper files.

4. With SOAP notes software designed for chiropractic clinics, you can easily access patient records remotely, from any device. When providers can find the information they need promptly, it improves workflows and increases the quality of care.

5. Illegible handwriting issues or incomplete documentation are greatly reduced with the use of online SOAP notes.

6. Using an affordable and integrated EHR system with the best chiropractic SOAP notes software greatly reduces the costs associated with paper notes, printing and storage costs, and personnel costs.

7. When all patient information is documented in digital form, it significantly reduces the risk of access by unauthorized users. With SOAP notes chiropractic software, your patient data remain safe and recoverable in the cloud.

8. The precision and thoroughness of patient documentation are greatly enhanced with the incorporation of specialized chiropractic software notes. This not only minimizes errors but also strengthens the overall patient care experience.

Why Chiropractors Need Automation in SOAP Notes Documentation

EHR software specifically designed for chiropractors include various SOAP note templates that help you accelerate the creation of SOAP notes for every patient who visits your office. A chiropractic software solution like zHealth Software enables you to customize SOAP note templates based on your practice needs and the techniques you use.

You can complete SOAP notes in 30 seconds. You just need a few seconds to create SOAP notes in an organized and legible fashion. Imagine the amount of time you will save by reducing the paperwork!

What to Look for in Digital SOAP Notes Software

• Chiropractor-Specific Software: Look for cloud-based chiropractic SOAP notes software and EHR platform designed for chiropractic practices. It should be easy to use and optimized for your practice needs.
• All-in-One Software: Look for all-in-one chiropractic practice management software. You will have one dashboard to manage your entire practice. You can ensure a consistent patient experience, automate repetitive tasks, eliminate the cost of papers, create SOAP notes in seconds, file claims with two clicks, and increase revenue and retention.
• Training and Customization: Choose a reliable chiropractic software provider that offers affordable pricing plans. The software vendor should provide a dedicated onboarding/training manager and customization support for chiropractic SOAP note templates.
• Multi-Device and Multi-User Optimized: The software you choose should be compatible with multiple devices like Mac, PC, iPad, or any mobile device, so that you can access your data, anytime, anywhere. The software should provide multiple user-specific logins for you and your staff.
• Integrated Billing: The software should help you generate matching SOAP notes and insurance claims. With an integrated billing tool, you will be able to submit claims with a few clicks electronically. It also helps to generate automatic patient balance payments and patient statements.
• Online Reputation Automation: You can automate your patient review collection process, gather feedback, promote positive patient experiences improve your online reputation on Google, Yelp, etc., and patient conversions with chiropractic software having an automated post-appointment feedback tool.
• Appointment Scheduling: Chiropractic software with an appointment booking management tool provides you with a transparent view of your patient appointments in a day, missed appointments, and more. You get to automate your patient appointment scheduling process, thus saving you time and reducing wait times. Integrated EHR solution with chiropractic SOAP notes software helps you send automated appointment reminders via text and email.
• Patient Recalls: Look for chiropractic practice software that enables you to improve patient recalls and follow-ups. Such software will automate the patient reactivation process by inviting them to book an appointment and check their progress.

How to Create SOAP Notes in 30 seconds with zHealth’s Chiropractic SOAP Notes Software

Crafting detailed and accurate SOAP notes is essential for providing quality patient care, In this blog post, we’ll explore how zHealth’s chiropractic SOAP notes software revolutionizes the way chiropractors document patient encounters, ensuring precision and efficiency in just 30 seconds.

1. Use Custom SOAP Note Templates

Customizable templates empower you to swiftly create SOAP notes tailored to various chiropractic techniques or your specific practice requirements. This feature accelerates the process of generating comprehensive and accurate SOAP notes, ensuring efficiency and precision in your documentation.

Creating SOAP notes becomes a breeze with zHealth’s extensive library of customizable templates. Chiropractors can choose from a variety of pre-designed templates tailored to specific techniques, including Blair, Gonstead, Activator, and others. Using custom SOAP templates ensures consistency and accuracy in documentation while saving valuable time.

Here are some chiropractic SOAP notes templates available in zHealth:

Chiropractors can significantly benefit from zHealth’s chiropractic SOAP notes chiropractic templates in several ways:

a. Time-saving: Streamline your documentation process, reducing the time spent on note-taking.

b. Precision: Ensure accurate and detailed SOAP notes for improved patient care.

c. Accessibility: Access your SOAP notes anytime, anywhere, with cloud-based storage.

2. Voice Dictation for Lightning-Fast SOAP Notes

Voice Dictation is a cutting-edge feature designed to revolutionize the creation of SOAP notes. With this speech-to-text technology, chiropractors can verbally dictate their observations, findings, and treatment details, allowing the software to transcribe their spoken words into written text.

Providers can complete their notes swiftly by speaking into the system, allowing for real-time documentation without the need for manual typing. Voice Dictation not only enhances efficiency but also contributes to a seamless and natural workflow in chiropractic documentation.

zHealth’s SOAP notes chiropractic software is equipped with Voice Dictation technology, making it easier than ever for chiropractors to create detailed and accurate SOAP notes. This innovative feature not only saves time but also enhances the overall documentation experience.

3. Build Your Own Templates

Tailor SOAP note templates to match your practice’s unique requirements. zHealth enables chiropractors to build personalized templates that align with their specific patient population, treatment approaches, and documentation preferences.

The Self Service SOAP Notes Builder in zHealth’s chiropractic software puts the control in the hands of chiropractors, enabling them to customize SOAP notes according to their workflow and documentation requirements.

With the ability to modify templates on-the-go, providers save valuable time, ensuring that SOAP notes are not only comprehensive but also created in a swift and efficient manner. The result is a seamless integration of personalized templates into the documentation process, contributing to a more streamlined and effective chiropractic practice.

4. SALTing Your SOAP Notes

SALT stands for Same as Last Time. This feature allows you to apply the same notes, diagnoses, and charges as the patient’s previous appointment. You can change only what’s different for the current visit. It is a useful time saver in documenting the patient’s visit when nothing has changed.

SALTing allows you to maintain consistent records, avoid data entry errors, and help patients understand their ongoing history and treatment plan.

zHealth Software – All-in-One Chiro Software

zHealth allows chiropractors to embrace digital SOAP notes documentation with our more intuitive and affordable chiropractic EHR system. Chiropractors can create patient notes 61% faster than with manual entry and save hours every week.

If you would like to explore the possibilities of zHealth, take a look at our pricing and plans. If you’re ready to sign up, contact our expert to request a free demo.