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Overview on SOAP notes
Health practitioners are required to document the treatment of their clients and any progress observed as part of their health record management. Certain information needs to be included in these notes, and different formatting structures have been created to assist practitioners in this process, including SOAP.
How do you write a SOAP note assessment?
Subjective (S): Subjective reflections and opinions regarding the behavior and treatment of the client. This section often includes direct quotes from the client.
Object (O): The practitioner’s data and information, including results from tests and assessments.
Assessment (A): A conclusive assessment made by the practitioner based on their observations of subjective and objective information.
Plan (P): Provides details of the treatment plan devised for the client. This section also includes information about the objectives and goals of the client and when the next session will take place.
Do chiropractors use SOAP notes?
All health practitioners must create organized clinical notes, and chiropractors are no exception. SOAP notes help inform chiropractors of whether their treatment methods are working and are valuable for documenting progress. Chiropractors can also use their SOAP notes as a reference point for patients who experience similar injuries.
They are also used in certain legal cases where correct procedure and patient quality of care need to be proved. Writing effective and thorough SOAP notes will significantly help patients receive the treatment they need while protecting the chiropractor against potential lawsuits and other challenges. Various tools and techniques can assist with the process of creating SOAP notes, and some of these resources, including free chiropractic soap note templates and descriptions, are provided below.
What are SOAP notes in chiropractic?
Chiropractors often use SOAP notes to document the treatment and progress of their patients. As mentioned above, these notes involve four sections: objective information, subjective information, assessment, and plan. To consolidate your understanding and illustrate precisely what SOAP notes for chiropractors look like, we have compiled examples of the information needed within these notes.
Medicare chiropractic soap note template
Medicare requires SOAP notes to be specific and detailed, and the best way to understand how this information should be included is by looking at a template example.
Chiropractic documentation examples
Although the general information relating to each of the SOAP note sections has been included above, the following example will demonstrate the specific parts of a chiropractic session that need to be documented:
Subjective (S): The specific injury/pain experienced (e.g., neck pain) and when the patient says they first noticed it. Detail how painful the injury is and whether the patient has tried any treatments themselves.
Objective (O): Results of inspections of the area of interest; test results including orthopedic tests and pain assessments.
Assessment (A): Diagnosis and prognosis of injury, as well as any progress, noted. For example, following treatment, the patient has a sub-acute sprain, an improvement from the acute sprain identified in the last session.
Plan (P): Document any referrals that the patient needs, when improvements and progress can be expected, and when to have another session. Also, discuss changes to general lifestyle, for example, encouraging the patient to sit in a supportive chair while at work.
10 Effective tips on writing chiropractic SOAP notes
The process of documenting practical SOAP notes can be both daunting and time-consuming. To help you write the best chiropractic SOAP notes possible, we have curated some helpful tips:
- The Sooner, the Better: SOAP notes are a critical part of every session with your patients. To eliminate the possibility of falling behind on documentation, you should try to write your SOAP notes after each session, or at the very latest, at the end of each day.
- Don’t Underestimate Documentation: Although it may seem as though spending time writing good SOAP notes prevents you from seeing more patients or doing other work, in truth, part of the role of being a practitioner is keeping up-to-date, accurate documents.
- Quality, Not Quantity: The essential part of every piece of documentation is the quality of the information you include. SOAP notes can be brief, but this should be due to removing vague wording rather than failure to include relevant information. All details relating to the patient’s injury, treatment, progress, and plans need to be contained within the notes.
- Be Careful with Templates: Although templates can give chiropractors, especially those new to the practice, a good idea of the information that can be included within SOAP notes, they can also be problematic. Many chiropractic SOAP note templates will consist of tests and assessments that are not relevant to treating the specific injury. It may be better to adjust these templates so documented information is solely applicable to the patient.
- Accessibility: After writing SOAP notes, chiropractors must organize their documents to be easily accessed. One of the most effective ways to store SOAP notes is using an online, HIPAA-compliant service.
- Storage: As crucial as accessibility, chiropractors need to safely store their SOAP notes to guarantee patient privacy.
- Treatment: The final section of writing SOAP notes requires you to detail the treatment plan for the patient. You should include information about the healing period for the injury, and when the patient should book another appointment - likely, they will not know.
- Legibility: Although it may seem obvious, chiropractic notes need to be legible as they are often read by people other than the practitioner who wrote them. If you have messy handwriting, convert to writing your SOAP notes online.
- Listen to the Patient: It is crucial to record any injuries or pain that the patient says they are feeling, even if it seems unrelated to what you were initially treating. Injuries may be related, and these records can help with future diagnoses.
- The Dead Doctor Rule: A simple method that chiropractors can use to ensure that their SOAP notes are as effective and accurate as possible is known as the dead doctor rule. If you suddenly died, would another chiropractor be able to read your notes and understand the patient’s injury, treatment, and progress? If so, the documentation is adequate.
Final Thoughts
Writing effective SOAP notes is a critical aspect of effective and accurate documentation for chiropractors. SOAP notes need to be concise, clear, and thorough. They should include the patient’s injury, when the injury began, results of tests and assessments, treatments and any progress that has been observed.
Following a template or example SOAP note can indicate the various aspects of chiropractic sessions that should be documented. SOAP notes allow chiropractors to determine how much their patient has progressed and whether their treatment is working. These documents can be used as references for other patients with similar injuries and are often required by Medicare and legal situations. Chiropractic SOAP notes software has been developed to assist with creating, organizing, and storing notes, helping establish effective chiropractic therapy.
The best SOAP note templates for Chiropractors and their clients: Try Carepatron for free today!
Further Reading:
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