The mnemonic term SOAP – Subjective Objective Assessment Plan – was devised as a way for doctors to document their patient’s progress. The SOAP note style is best used during routine office visits vs. the initial visits of episodes of care, which are laid out in an Evaluation and Management (E/M) style.

When documenting the routine or follow-up visits within an episode of care, keep the meaning of each letter in SOAP to ensure the note is thorough and complete. Standardized notes, such as the SOAP style, are essential so that the records are easily understood by any healthcare provider. SOAP notes can be short and succinct as long as they contain all the information required. Third-party payers, boards of examiners, and other interested parties use the SOAP note to easily evaluate the patient’s progress over time. Medicare requires specificity in SOAP notes, and you can use the Medicare requirements for every patient in your practice.

Routine Office Visit SOAP Note Must-Haves

S:  Include the patient’s subjective view of their symptomatology, including the status of progress toward functional goals set at the beginning of care. These can be expressed in the context of “changes since the last visit”, pain scales, and “same/better/worse”. Each of these should include a brief description of how the patient has come to this opinion. For example, “the pain is better than last time, and I feel improved because I can sit longer without pain”

O:  As the provider strives to quantify the patient’s subjective comments above, include objective findings and evidence of changes since the last visit, whether same, better or worse. Although Medicare doesn’t require the PART process on a routine visit basis, documentation of Pain, Asymmetry, Range of Motion, and Tissue/Tone changes through palpation is an excellent guideline to follow.

A:  Daily assessment is the provider’s opportunity to share their thoughts on how the patient is improving or not, and why they do or don’t need more treatment. Additionally, any exacerbations or other setbacks may be explained here. If lab or imaging results have been received or reviewed in the visit, or there has been a change to the diagnosis, this is where they will be listed.

P:  The “plan” section of a SOAP note is meant to outline the treatment rendered on this visit. Chiropractic manipulation documentation must include the segments adjusted. Ancillary treatment, such as modalities and procedures performed on the visit are described including location, muscle groups, sets, reps, unit time, and/or total time, if applicable. Changes to the plan made on the visit are also outlined. If the patient is discharged on the visit, for example, this is where the episode of care is summarized and closed out.

SOAP Notes Protect You

When billing third-party payers, it’s the daily SOAP note that must align with the charges for the day. Not only do these notes describe the services rendered, but more important, they outline why…a key element in documenting medical necessity. The SOAP notes should read like a story of the patient’s experience in the practice. This is crucial when it comes to evaluating treatment effectiveness.

ChiroTouch and SOAP Notes

With ChiroTouch, you can feel confident that all the required aspects of SOAP note documentation are considered and included in the outline of the note. The software was designed to prompt the provider to reflect on each required element to ensure the note is detailed and complete. That’s peace of mind and certainty that is priceless for today’s practitioner.

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