Learn how to take stronger SOAP notes with less work to optimize your time in this free ebook!

You Will:

  • Learn how the right chiropractic software can help you work smarter, not harder. 
  • See how we enable chiropractors with the tools they need for faster, compliant SOAP notes. 
  • Discover how integrated systems help you collect more info in less time.
  • Find tips on how to spot a SOAP software that will make you more efficient.
  • Get tips and tricks to optimize the way you work. 
  • Take a close look at the essentials of practice efficiency and more!

Excerpt

Your SOAP notes are an essential part of practice management because they enable providers to create audit-proof documents while simultaneously ensuring billing and coding accuracies. In today’s chiropractic practices, technology is no longer optional, especially when creating chiropractic SOAP notes.

Ask yourself: do you go through reams of paper every month writing SOAP notes? Do you face challenges with scheduling and intake? How do you handle maintaining patient records and billing? If you don’t have an efficient way of managing the back-office tasks that your practice requires, you’re missing out on what’s most important: caring for your patients.

This guide discusses how software explicitly designed for chiropractors, like CHIROSPRING, can improve your chiropractic SOAP notes and how you manage the rest of your practice.

Key Takeaways:

  • Learn what chiropractic SOAP notes are, their importance, their benefits, and how they optimize how chiropractors care for patients.
  • Understand how using connected systems increases SOAP note efficiency.
  • Identify the common headaches that chiropractors face when writing SOAP notes and how connected systems can optimize the process.

What Are SOAP Notes?

The most common method for documenting patient care and treatments is using chiropractic SOAP notes. SOAP is an acronym for subjective, objective, assessment, and plan, with each of these words split into separate sections that help chiropractors use SOAP notes to optimize how they care for patients.

Section 1: Subjective

Chiropractors use this section to create an easy-to-read document outlining the patient’s initial complaint. They can streamline the process even further by including data about the patient’s past medical history and other pertinent information received during their intake. This section is “subjective” because it describes the patient’s pain and their experience with the condition.

Section 2: Objective

In this section, chiropractors compile their measurable findings and other data that they gather regarding the patient’s complaint. Having this patient data all in one place makes it easy to find and refer to during treatment. This information could include detailed inspections of their initial complaint, imaging studies, neurological tests, and orthopedic tests.

Section 3: Assessment

The assessment section of chiropractic SOAP notes is where chiropractors document the patient’s outcomes, including their diagnosis and prognosis. By having this data in an easy-to-find format, chiropractors can take the information and move forward with the patient’s care and treatment plan, efficiently and in an optimized way. All the data they need is in one place and includes the patient’s condition, their response to treatment, changes in their condition, and patient goals during treatment.

Section 4: Plan

Chiropractors use this section to outline how they plan to move forward regarding addressing the patient’s condition. Planning is straightforward and streamlined in chiropractic SOAP notes so providers can quickly refer to every other section. Then, they can devise a care plan that includes the expected duration of care, lifestyle modification, lab work ordered, referrals needed, and more.

The Importance of SOAP Notes

Every medical professional must keep track of their notes during patient care, and chiropractors are no exception. Chiropractic SOAP notes are a straightforward way of documenting every stage of a patient’s care and treatment plan. The structure of SOAP notes creates a streamlined method for recording everything from the patient’s initial complaint to their symptoms and onward to their care plan. They ensure that the most up-to-date and relevant patient data is immediately available, organized, and available in easy-to-find places.

A critical reason for using this form of note-taking is that it cuts down on the potential for miscommunications. For example, if two facilities provide care for a patient and use the same note-taking format, they’ll have the same information and ensure that the patient receives the best care. Other factors increasing the importance of SOAP notes include the following.

Keeps chiropractic practices compliant

HIPAA defines many regulations regarding completing and maintaining patient records. SOAP notes create the formal documentation procedures that chiropractic practices must uphold during patient care. This documentation also helps your practice maintain patient privacy if you’re using HIPAA-compliant chiropractic software, like CHIROSPRING.

Justifies charges during third-party audits

Create audit-proof chiropractic SOAP notes that ensure that your practice is compliant with HIPAA, among other industry standards. If you must undergo a third-party audit, SOAP notes prove that providers within your practice follow proper procedures. This documentation makes it easy to justify all charges when third parties must conduct a payer audit. The information within your SOAP notes also plays an integral role in defending yourself against malpractice charges.

Enables providers to understand patient records easily

It isn’t uncommon for patients to need to see more than one provider during their treatment plan. In this case, SOAP notes are essential. More than one provider can access and use this documentation, which helps optimize the treatment process. There’s no longer the need for tracking down records, test results, and other pertinent data. Instead, everything that they need is available in an easy-to-understand format.

Provides the specificity that insurance companies require

Chiropractic SOAP notes streamline a patient’s care and treatment from the time that they complete intake to when they submit insurance claims. Insurance companies require chiropractic practices to send them copies of the patient’s patient records to verify the claims that they submit. Providers can easily substantiate the billing claims that they submit by properly documenting patient records.

Helps providers determine how to address complaints with proper diagnoses and treatment

Chiropractic SOAP notes create a streamlined way of proving patient interaction and determining how to diagnose complaints with the property diagnosis and treatment. Providers can use SOAP notes to document every patient interaction and their treatment progression. By keeping track of these interactions, providers can enhance their quality of care.

The Benefits of Using SOAP Notes

One of the many benefits of chiropractic SOAP notes is that they provide an efficient and prompt location for your patient’s treatment records. These notes are also beneficial for optimizing the treatment process in that they enable providers to formulate strategies regarding how to meet their goals. SOAP notes provide a clear picture of the patient’s health, past medical history, and complaints to better position them for a better diagnosis. Here are a few additional benefits.

Automatically copy over previous content notes

Reduce the chance of losing patient data with automatic integration, which means you can optimize the note-taking process within your practice due to CHIROSPRING automatically copying over previous content notes. This feature reduces the likelihood of data coming up missing and the need for typing in the same data numerous times.

Use touch interface during exams

Managing patient complaints is easier using the intuitive touch interface in chiropractic SOAP notes software like CHIROSPRING. Touch interfaces enable providers to create digital records for patient complaints quickly. Since the progress automatically integrates into a graph, providers can easily show patients the progress that they’re making during treatment.

Use macros for textual input without typing

SOAP macros mean there’s no longer the need to type. Each time that providers click, complete sentences and paragraphs automatically generate. When providers use CHIROSPRING’s chiropractic SOAP notes, they’ll find hundreds of macros available, each editable and customizable. Chiropractors can also input their own.

Have SOAP subjective automatically populates

Save time by letting your patients automatically populate their SOAP notes during online intake. CHIRSPRING enables patients to populate much of the note. That subjective includes custom intake questions, documented complaints, outcome assessments, and review of symptoms. Providers have complete control of this digital content and can make edits to the SOAP note if necessary.

How Using Connected Systems Increases SOAP Note Efficiency

Even though chiropractors want to take a hands-on approach to treating their patients, that doesn’t mean technology shouldn’t also be a priority. When creating chiropractic SOAP notes, connected systems can further optimize the process and are beneficial for improving chiropractic SOAP note efficiency.

What Are Connected Systems?

Connected systems link data inputs to processes, knowledge, and users. These systems do much of the work for providers when they create SOAP notes. For example, the provider or their staff members don’t have to worry about searching for codes, inputting a significant amount of text, or sifting through patient records. Since everything they need connects automatically to their SOAP note, that integration optimizes the entire process.

Real-time connectivity means providers receive the patient’s current information as soon as it updates to the system. From when a patient completes the intake process to when staff members upload pertinent records, chiropractors can access this information. Connected systems play an integral role in chiropractic practices regarding compliance and patient access.

How Technology Transforms Your Practice

Chiropractic software connects chiropractic SOAP notes with scheduling, electronic health records (EHR), billing, and more. This technology optimizes and transforms practices in many ways by streamlining every step of an exam.

Why technology must be at the forefront of your mind

We live in a digital age, and patients expect chiropractors to have the technology necessary to run their practices efficiently. That ranges from when they complete their intake to when they receive their treatment plan and everything in between.

The only way for chiropractors to take comprehensive—and compliant—SOAP notes is by using the best chiropractic software, like CHIROSPRING. This way, chiropractors can chart a patient’s progress in real time and provide them with specialized care.

How technology keeps patients healthy in a cost-effective manner

Technology helps providers keep their patients healthy in a cost-effective manner by enabling them to see what the patient’s complaint is, any previous tests already completed, what tests they still need, and how far along patients are in the treatment process. Patients can rest assured that they won’t receive treatments that they don’t need, and chiropractors can continue working to improve their health and quality of life.

How using EHR creates automatic workflows and efficient SOAP notes

The single-click feature available through CHIROSPRING means providers can access a patient’s EHR and automatically integrate it into their current SOAP note. This integration streamlines the exam process and automates workflows. The real-time features available in this software increase efficiency, while chiropractors can create error-free and audit-proof chiropractic SOAP notes.

The Benefits of Embracing Digital Trends in Your Chiropractic Practice for SOAP Notes

If you and your staff are still wasting time hand-writing notes, answering phone calls, or working on other back-office tasks, you’re missing out on what’s most important: delivering the highest quality care to your patients. There are several benefits to embracing digital trends in chiropractic practices for SOAP notes, including the following. 

Create customizable SOAP notes

Not every patient receives the same care or has the same treatment plan. Every part of CHIROSPRING’s chiropractic software is completely customizable. That extends to being able to customize all parts of a chiropractic SOAP note and includes arranging and pinning standard charges, diagnosis favorites, and macros. If you don’t use SOAP note exams, tabs, or treatments, you can easily remove them.

Manage patient complaints

Managing patient complaints is easier than ever, thanks to this software’s intuitive touch interface. It enables providers to record complaints quickly using a digital body. As the patient continues moving forward with their treatment, CHIROSPRING automatically generates a graph charting their progress.

Customize patient care plans

When providers use chiropractic software’s patient care feature, they can create and track prescribed services. Customized patient care plans can also include optional discounts, or providers can use this feature to generate estimates. The templates available also help providers save time when creating and prescribing care plans.

Save time using online intake

The online intake process enables patients to populate much of their SOAP notes automatically. So, when a patient completes their online intake information, it automatically populates into the SOAP note feature. This information includes documenting their initial complaint and symptoms. They can also include any outcome assessments that they have. Providers can customize the intake process even further by writing custom intake questions, thus giving them complete control of the content that they receive.

Use SOAP macros to generate complete sentences or paragraphs

There’s nothing more frustrating than when your patient spends more time sitting and waiting for someone to finish typing instead of receiving the treatment that they need. CHIROSPRING’s preloaded macros speed up the typing process by eliminating it. When providers are writing SOAP notes, they don’t have to waste time typing information in. Instead, with one click, they can input single words, sentences, or paragraphs automatically.

Complete evaluations

Streamlining the evaluation process is straightforward when using software specifically designed for chiropractors. Real-time technology optimizes the exam process by enabling providers to pull previous exams into the patient’s current SOAP note. There are several evaluations that chiropractors must complete, and the touch interface streamlines the process for each, including the following examples:

  • Cranial nerves
  • Muscle strength analysis
  • Muscle tone analysis
  • Orthopedic tests
  • Outcome assessments
  • Pediatric tests
  • Range of motion
  • Reflexes
  • Sensory tests
  • Special tests
  • Vascular tests
  • X-ray analysis

Common Headaches That Chiropractors Face When Writing SOAP Notes

Chiropractors are busy, and if chiropractic SOAP notes aren’t efficient, it takes too long to write (and edit) them. If there are too many paper records, that means there’s a greater chance of miscommunications or losing important documents. Unless providers incorporate efficient SOAP note software into their practice, they’ll face one or more of the following headaches.

Not Having an Auto SALT Feature

Providers need access to every part of the patient’s record during visits. They might need to reference a previous visit, view test results, and more. Without an auto SALT (Same as Last Time) feature, providers must manually enter patient data into their notes during every visit. This lack of automation takes up a considerable amount of time, which providers should be spending with their patients face to face.

Not Documenting CPT Codes

CPT (Current Procedural Terminology) codes are standardized terms and codes relating to the medical procedures that providers must use on insurance claims and patient records. Chiropractors need these codes to ensure that their billing is accurate and to tell insurance companies what procedures they performed that need reimbursement. If the codes aren’t automatically populating in the SOAP note software, there’s a chance that their billing won’t be as accurate as it should be.

Wasting Time Reviewing Old Notes

Chiropractors need to review old notes to ensure that they’re on the right track with their patient’s care. They use this data to track progress, see how the patient’s condition changes over time, and look up any discrepancies that they might see within the patient’s record. A connected system helps streamline this process and prevent providers from wasting valuable time sifting through patient data.

How Connected Systems Streamline SOAP Notes

CHIROSPRING is a unique software specifically for chiropractors that streamlines the SOAP notes process. It benefits chiropractic practices because it reduces or eliminates many of the common headaches that chiropractors face. The connected systems available through this software streamline SOAP notes, thus preventing staff burnout and freeing up the additional time that practices need to spend with their patients.

Auto SALT

The auto SALT feature means you can automatically retrieve a patient’s chart notes, charges, diagnosis, treatment progress, and more. CHIROSPRING has a built-in SALT button that enables you to copy adjustments from previous to current visits quickly and easily.

Large quantities of SOAP note information, including exams notes, can auto SALT, a feature that saves chiropractors a significant amount of time. Suppose that a patient comes to a chiropractor’s office for a spinal adjustment. During subsequent visits as part of their treatment plan, their provider can click the SALT button to transfer data over automatically.

Charge Groups

Optimize the billing process within SOAP notes using charge groups set up automatically by CHIROSPRING. The software organizes the practice’s insurance charges automatically. This way, they can quickly identify all the revenue that it brings in.

Charge groups are also editable, including adding notes and resubmitting as necessary. Suppose that a provider uses a SOAP note to create an insurance billing claim. They can use the integrated charges to optimize the process and reduce the chances of discrepancies or inaccuracies.

Document Uploading

Chiropractors who want to run a 100% paperless practice can achieve that goal using CHIROSPRING’s document-uploading feature. Sifting through reams of paper generates clutter, creates opportunities for record misplacement, and slows down how practices operate.

Paperless operations optimize the practice. Suppose that a patient brings records to the practice from a different provider. Document uploading enables staff members to integrate those records into the patient’s file seamlessly for quick reference. After uploading documents, staff and providers can put them into custom folders, tag them, and more.  

Single-Click Charges

CHIROSPRING’s single-click feature enables staff and providers to pull exam dates quickly into current chiropractic SOAP notes. This feature simplifies the exam process due to the software’s touch and single-click interface.

It also can quickly pull exam information from previous visits into the current SOAP note. Suppose that a patient comes into the practice to continue their spinal adjustment treatment plan. The provider can automatically pull records from the previous testing into the patient’s current exam.

SOAP Text

The SOAP text feature enables chiropractors to create texts associated with treatment charges. The text that they input automatically appends to their SOAP note, enabling them to create audit-proof charges. Combine this feature with CHIROSPRING’s macros, and chiropractors don’t have to spend as much time typing information into SOAP notes.

For example, as chiropractors create a SOAP note, the SOAP text and macros features streamline the process. They can use a single click to create entire sentences, reduce the amount of time to write SOAP notes, and increase their time treating patients.

Create Thorough Chiropractic SOAP Notes

Previously, there was no practical way to tell if chiropractic notes were thorough or not. CHIROSPRING’s SOAP note feature enables providers to create audit-proof documents that any other provider could use to treat patients if they had to take over the practice for whatever reason. This chiropractic software is easy to set up and fully automates your entire practice. It has the connected systems that you need to automate processes, including appointment reminders, billing, charges, in-take, and chiropractic SOAP notes.

CHIROSPRING is an all-in-one practice management and EHR system built specifically for chiropractors to help them regain face-time with patients, spend less time on back-office tasks, maintain a limited staff, and save operational costs.To see how CHIROSPRING can help you simplify how you manage your practice, reach out to one of our specialists today!