What to Include in Your Chiropractic Practice SOAP Notes

Highlights

• A chiropractic SOAP note contains the patient’s subjective complaints, objective findings from the physical examination, a chiropractic assessment and diagnosis, and a detailed treatment plan.
• Chiropractic SOAP notes provide a roadmap of care for your patients and help you link billing with the day’s treatments.
• SOAP notes are essential for cash-based and insurance-based chiropractic practices.
• Chiropractic EHR practice management software like ChiroTouch allows you to complete SOAP notes quickly and efficiently.

Chiropractic SOAP notes help organize patient care workflows and are required for healthcare providers.

Chiropractic SOAP notes should include specific details to ensure compliance and streamline billing.

The subjective section (S) should document the patient’s chief complaint, history of present illness, past medical history, and social history. The objective section (O) must detail the physical examination findings, including a range of motion assessments, orthopedic tests, and neurological examinations. The assessment section (A) should clearly diagnose the patient’s condition, linking it to the findings in the subjective and objective sections. Finally, the plan section (P) should outline the treatment plan, including specific chiropractic adjustments, modalities, and exercises.

Chiropractors can create accurate and comprehensive SOAP notes that support precise coding and billing by including these essential elements.

However, staying on top of this documentation can be challenging if you’re using inefficient EHR software that lacks features like custom macros and auto-sync.

ChiroTouch solves this issue by enabling quick and easy SOAP note entry, ensuring you meet compliance standards in seconds while delivering high-level patient care.

Chiropractic SOAP Notes Checklist: What to Include

A complete chiropractic SOAP note should include the patient’s subjective symptoms, objective examination findings, clinical assessment, diagnosis or progress update, and treatment plan. For chiropractic practices, SOAP notes should also document medical necessity, treatment regions, patient response, functional limitations, and any changes from the previous visit. Include:

• Patient’s chief complaint
• History of present illness
• Pain level and symptom changes
• Functional limitations or ADL impact
• Objective exam findings
• Range of motion findings
• Orthopedic or neurological test results
• PART findings when applicable
• Diagnosis or clinical impression
• Patient progress since the last visit
• Treatment provided during the visit
• Regions adjusted or treated
• Modalities, exercises, or therapies performed
• Plan for continued care
• Billing and compliance details that support medical necessity

What Are SOAP Notes? Why Are They Important for Chiropractic Practices?

SOAP notes are a method of documentation used in the healthcare industry to document a patient’s diagnosis and treatment. The SOAP (Subjective, Objective, Assessment, and Plan) notes framework helps practitioners keep track of their patients’ progress during treatment. It also provides a detailed reference tool that providers can consult during future chiropractic sessions to adjust treatment plans or reevaluate diagnoses for more effective patient management.

For chiropractors, maintaining SOAP notes is essential. SOAP notes keep you in compliance with reporting and licensing requirements. They provide chiropractic documentation for third-party providers or boards of examiners who may ask to review the patient’s treatment information.

They also help you structure patient visits to achieve a high level of care that meets their needs. Using SOAP notes helps your patients feel heard and receive personalized treatment for their concerns.

See how your team can save time on SOAP notes

Routine Office Visit Chiropractic SOAP Notes Must-Haves

To accurately complete SOAP notes for your chiropractic patients, you’ll want to follow the Subjective, Objective, Assessment, and Plan structure. Include the following information for each category to ensure complete, accurate notes.

Subjective

The subjective section of your SOAP notes includes the patient’s description of their chief complaint, their current medical condition history, and how it affects their activities of daily living (ADLs).

Treatment history includes information such as when the complaint started, where it is located, the duration of the complaint, the severity of pain, and whether the discomfort radiates to other parts of the body.

If the patient is returning for a follow-up visit, document these notes as changes since their last session, including pain scale ratings and same/better/worse self-assessments. Each of these should briefly describe how the patient arrived at this opinion.

For example, the patient may report, “The pain is better than last time because I can sit longer without discomfort.”

Objective

The objective section of chiropractic SOAP notes helps quantify the patient’s personal comments. Include objective findings and evidence of changes since the last visit. Record evidence that shows whether the patient is the same, better, or worse since you last saw them.

Use the Pain, Asymmetry, Range of Motion, and Tissue/Tone changes (PART) documentation method indicated by the Centers for Medicare and Medicaid Services. This approach provides a thorough and objective assessment of your patient’s current state of health and mobility.

Assessment

The assessment portion of chiropractic SOAP notes lets you share your thoughts about your patient’s improvement or decline. You can also record your recommendations for future treatment outcomes, potential setbacks, or any other relevant assessments you’ve made.

The assessment portion is also the section to record lab or imaging results or changes in diagnosis.

Plan

The final section of chiropractic SOAP notes outlines a plan for treatment the patient receives during their visit. Chiropractic spinal manipulation documentation must include the regions of the spine you adjust.

You must also record ancillary treatments using specialized chiropractic tools and equipment, such as transcutaneous electrical nerve stimulation (TENS) or therapeutic ultrasound, including location, muscle groups, sets, reps, unit time, and/or total time. You should also record changes to the plan made on the visit and note if you discharged the patient after the session.

Chiropractic SOAP Note Sections at a Glance

Each SOAP note section serves a specific purpose. The subjective section records what the patient reports, the objective section records measurable findings, the assessment section explains the chiropractor’s clinical interpretation, and the plan section documents treatment and next steps.

Common Chiropractic SOAP Note Mistakes to Avoid

Common chiropractic SOAP note mistakes include vague documentation, missing objective findings, incomplete treatment plans, and notes that do not clearly support medical necessity. These gaps can make it harder to justify care, support billing, and maintain compliant records. Avoid:

• Using vague phrases without measurable findings
• Repeating the same note without documenting patient progress
• Leaving out pain scale updates or functional limitations
• Failing to connect objective findings to the assessment
• Omitting the spinal regions or areas treated
• Not documenting modalities, exercises, sets, reps, or treatment time
• Missing changes to the care plan
• Failing to show why treatment was medically necessary
• Documenting billing codes that are not supported by the note
• Waiting too long after the visit to complete documentation

SOAP Notes Protect You

In addition to maintaining accurate electronic health records for chiropractors to track your patients’ care and progress, SOAP notes can protect your practice from insurance audits and hefty fees due to violations of CPT coding procedures. If you run an insurance-based practice, your SOAP notes must align with the charges your chiropractic biller submits to third-party payers.

Your SOAP notes describe your services and explain why a patient receives a particular treatment. This is essential for insurance because reimbursement depends on the treatment being medically necessary.

Keeping accurate and detailed SOAP notes ensures your treatment improves the patient’s well-being. It also provides documentation for third parties who rely on the information for payment and assessment.

Chiropractic SOAP Note Best Practices

The best chiropractic SOAP notes are accurate, specific, timely, and easy to connect to the patient’s care plan. Strong documentation should clearly show what the patient reported, what the provider observed, how the patient is progressing, and what treatment was provided.

• Complete SOAP notes as close to the patient visit as possible.
• Use consistent templates for routine visit documentation.
• Include measurable findings instead of general descriptions.
• Document changes from the previous visit.
• Connect the assessment to the subjective and objective findings.
• Clearly explain medical necessity.
• Record all services, regions treated, and modalities used.
• Update the treatment plan when the patient’s condition changes.
• Use macros carefully so notes remain specific to each patient.
• Review documentation regularly for billing and compliance accuracy.

ChiroTouch and SOAP Notes

To maintain accurate SOAP notes for your chiropractic practice, turn to an all-in-one chiropractic EHR practice management system.

ChiroTouch is an industry leader in chiropractic software, which benefits your practice by providing several features to support easy, convenient treatment and diagnosis entry.

BulletTouch Macros

One of the best features of ChiroTouch is the ability to customize SOAP notes and macros to the style that each practitioner wants.  All chiropractors are different and want to document in their own verbiage, and ChiroTouch levels up your chiropractic practice with easy-to-use macros.

Our charting macros are 100% customizable through the charting portion of the dashboard. With them, you can create a functional SOAP template that allows you to complete patient charts in as little as 15 seconds.

ChiroTouch macros also help you to standardize your practice’s patient notetaking so you can share custom templates with colleagues.

Easy To Access

Since ChiroTouch is cloud-based, patient SOAP notes are accessible from your desktop, laptop, or tablet. This allows providers to complete patient intake, exam, and assessment and create treatment plans from their iPads while the patient is in the room.

Easy SOAP documentation also allows chiropractic assistants to access patient information for billing and sending appointment reminders.

Auto SALT Feature

ChiroTouch’s auto SALT (same as last treatment) feature speeds up charting and record keeping for patients returning for further treatment.

The template within SOAP note saves you time by allowing you to enter the same chart notes, diagnoses, treatment plan, and fees from the patient’s previous treatment session with a single click, so you can update their notes in a few seconds.

Coding Compliance

Accurate CPT codes are crucial for improving billing accuracy and ensuring fast insurance processing to maintain your practice’s cash flow.

Medicare has strict requirements for coding, and ChiroTouch templates ensure that you are always CMS compliant.

ChiroTouch SOAP notes templates are designed to be audit-proof by including evidence-based treatment effectiveness and medical necessity. They are also compliant with evaluation and management guidelines required by third-party payers.

Patient Treatment Charting Is Easy With ChiroTouch

ChiroTouch’s all-in-one chiropractic EHR practice management software makes keeping up with treatment and diagnoses easy for your practice. Our customizable macros and automated features allow you to complete chiropractic SOAP notes in seconds so you can spend more time with your patients.

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