What are SOAP Notes?
The term chiropractic “SOAP notes” has nothing to do with working up a lather. It stands for “Subjective Objective Assessment Plan,” which provides documentation of a patient’s condition, diagnosis and treatment. SOAP notes were invented in the 1960s by Dr. Lawrence Weed of the University of Vermont and didn’t take long to enter widespread use in the medical profession. For practical office management purposes, SOAP notes are necessary for accurate coding and billing.
Subjective Objective Assessment Plan (SOAP)
It’s easiest to understand the SOAP notes concept when going over each component of this documentation.
Subjective – This is the patient’s chief complaint. In chiropractic, that’s likely back pain, neck pain, or some other neuromuscular issue. It’s subjective as it conveys the patient’s experience of their condition. On the initial visit, the doctor records the patient’s symptoms, when the pain began, the pain severity, and also takes a medical history. If trauma was involved, the patient is asked to explain the mechanism of injury. The first subjective note for a patient is generally much longer, as it contains the history elements. Subsequent subjective notes on follow-up visits should include any changes in symptoms or new symptoms, the current level of pain and how the pain has changed since the last patient visit, as well as an account of how the problem affects a patient’s daily activities and any functional improvements.
Objective – This part of SOAP includes the chiropractor’s measurable data of the patient, including data such as weight and measuring of vital signs. The results of any laboratory testing or imaging are included, along with findings from the chiropractor’s physical examination of the patient. The exam note includes all testing performed, such as orthopedic, neurological and range of motion. The daily notes include items such as asymmetry, palpatory pain, tissue changes and joint fixation.
Assessment – The assessment takes into account what the doctor learns from the patient’s information and the examination performed. The assessment includes the diagnosis and prognosis, and may also involve a differential diagnosis. When the diagnosis is unclear, the doctor should include possible diagnoses listed in order of most to least probable. This component includes a chiropractor’s assessment of the patient’s progress.
Plan – The plan communicates what the chiropractor will do to address and treat the patient’s condition. It includes any lab work ordered, therapeutic treatment and exercises, the expected duration and frequency of care, and any referrals needed. It also includes notes when a patient requires any type of lifestyle modification. During each patient visit, the chiropractor should note any adjustments or other services provided. Keep in mind that SOAP notes must prove clear and intelligible to a third party. If something happened to you and another doctor had to take over your patient’s treatments, could they easily get up to speed by reading your SOAP notes on the patient and continue treatment? If the answer to this question is a resounding, “Yes!” your documentation is clear and effective.
How to Use Chiropractic Soap Notes
The best SOAP notes are geared toward quality rather than quantity. While thorough notes are crucial, the most important aspect as chiropractor is to determine how to address a patient’s complaint by way of diagnosis and treatment. If SOAP notes don’t include the essential details, such as the exact type of pain and location, it is difficult, if not impossible, to truly assess treatment efficacy.
Detailed chiropractic SOAP notes provide you with thorough documentation. The lack of extensive documentation can really hurt you if you are ever sued. On the other hand, detailed soap notes can prove the plaintiff doesn’t have a case. SOAP notes help keep you compliant. If audited, they will prove you followed the proper procedures and billed patients correctly.
Chiropractic Soap Notes and Medicare
While SOAP notes are crucial for any patient, they are especially critical for those patients covered by Medicare. The rules for chiropractic SOAP notes for Medicare patients are stringent. Medicare’s specific guidelines require that records document symptoms bearing a direct relationship to subluxation levels. This means if a chiropractor doesn’t correctly document a subluxation, referring to the pain and tenderness, misalignment or asymmetry and range of motion abnormalities, Medicare may reject the claim.
ChiroTouch EHR and Soap Notes
Even under the best of circumstances, SOAP note documentation is a tedious task. The right EHR system makes creating your SOAP notes a breeze, and increasing the efficiency of your practice. A good EHR system saves you time and money; it lets you spend more of your day with your patients, rather than dealing with documentation. Soap notes really start with that initial patient appointment, so ChiroTouch software is with you for every aspect of the patient care process.
ChiroTouch’s macros allow you to complete your soap notes in 15 seconds. The macro is used in conjunction with the patient intake tool, so you can readily send your patient’s intake response to the subjective section of your soap note.