SOAP notes are crucial for documenting patient interactions. Even simple chiropractic SOAP reports can keep you on track and provide a log of patient assessments, treatments, plans, and outcomes. They should include four parts:
- Subjective: Subjective observations expressed by patients
- Objective: Objective factors that you can measure, see, hear, or feel
- Assessment: Chiropractor assessment, condition, and diagnosis (or preliminary diagnosis)
- Plan: Treatment plans, including any additional tests or care required
Taking consistent chiropractic SOAP notes has several important benefits.
The Benefits of SOAP Notes
The biggest benefit of SOAP notes is that they help chiropractors provide a better continuum of care throughout a patient’s lifecycle.
In nearly every practice, it’s impossible to remember the details of every single visit. Although you may remember the last time that you saw a patient, you don’t want to rely on your memory. By documenting the progression of interactions, you can easily see the impact of treatments and track patient progress over time, whether patients are improving on the course that you’ve set or if you need a change in protocol.
Dealing with insurance providers can also be a challenge. SOAP notes help justify charges to third-party payers. If there is a dispute, SOAP notes can help you reconstruct the timeline and treatments so you can get paid. Depending on the software that you’re using to record your SOAP notes, you may be able to use simple chiropractic SOAP notes to generate claims and billing statements.
For example, with CHIROSPRING, once you sign the SOAP note, claims are automatically created and ready for export with no additional work required.
SOAP notes can also be essential if you have to defend yourself in case of claims, such as a malpractice suit.
The Challenges of Writing SOAP Notes
There are also challenges associated with writing detailed SOAP notes. They can be time-consuming, especially when doing them manually. It can be easy to skip sections, leave out important details, or omit needed information. Waiting until the end of the day can lead to errors if you haven’t backed up your observations with supporting data.
Besides making errors, filing, tracking, and turning SOAP notes into billing can also be challenging. You need a way to provide the details that you need within simple chiropractic SOAP notes.
Essentials for Writing More Efficient SOAP Reports
Writing good SOAP notes is a deliberate process, and they should be created as soon as the patient interaction is over to capture the important details. Here are a few best practices for creating efficient SOAP notes for each of the four parts.
Use the OLD CARTS method.
- Onset: Determine when each symptom first started
- Location: Find out the primary location of the pain or discomfort.
- Duration: Learn how long the patient has dealt with their symptoms.
- Character: Examine the types of pain — aching, stabbing, etc.
- Alleviating or Aggravating Factors: Ask what actions or interactions reduce or increase the severity of the patient’s symptoms.
- Radiation: Find out if the pain radiates to other locations in the body.
- Temporal Pattern: Ask if the symptoms appear in a pattern, like in the evenings or after meals.
- Symptoms Associated: Ask if any secondary symptoms accompany the patient’s main complaint.
For the Objective section, make sure you write down data rather than conclusions. While you do want to record patient symptoms, you also want to document any observations that support or refute what the patient is telling you.
Here, you are not assessing the information, but rather recording it, along with any measurable data.
In this section, you need to synthesize the data in the previous two sections to make an unbiased evaluation based on data.
You may or may not include a diagnosis in the initial phases, but you should provide a preliminary diagnosis and indicate any additional testing or assessment that needs to occur. Follow-ups should include an independent evaluation of the impact of treatment.
The plan section should include the treatment plan, treatments given, and an explanation for why you are following this course of action. You should indicate any immediate response to treatment, along with follow-up actions, including future visits.
It’s also important to list goals and outcomes and note changes in the plan over time if necessary.
How CHIROSPRING Makes SOAP Reports More Efficient
CHIROSPRING provides chiropractors the ability to write fast, audit-proof, and simple chiropractic SOAP notes. A touch interface enables you to view or pull up previous notes, and macros greatly reduce the need for text input to improve speed. You can spend more time assessing and treating patients rather than recording information.
One thing chiropractors love about CHIROSPRING is that the online intake from patients automatically populates the Subjective section of the SOAP notes, including outcome assessments from patients. This saves time and reduces the need to transcribe information or force patients to repeat assessments.
You can customize the format of your SOAP notes for the way that you want to work. Built-in modules make it simple to record pre-built evaluations. You can see patient progress over time in graphs, so you can show your patients their improvements. You can also quickly create and track prescribed sets of services and generate estimates.
You’ll also have these features:
- Auto-SALT (Same as Last Time) Notes: Click a button, and copy procedures or notes from the last visit to save time.
- Charge Groups: Automatically set a diagnosis, and CHIROSPRING’s software will organize every insurance charge.
- Single-Click Changes: Quickly pull a previous exam into the current note, and make changes with a single click.
- Document Uploads: This feature enables you to run a 100% paperless office. Notes or supporting documents can be uploaded in any form and attached to patient records for reference.
CHIROSPRING’s SOAP notes can standardize your records and ensure that they are fully compliant with regulations and external audits. SOAP notes are kept in a secure cloud database. CHIROSPRING also automatically updates your software for patches and security updates, so you don’t have to worry about it.
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