As a healthcare professional, you’re probably familiar with SOAP notes, and may already use them yourself. The acronym SOAP (Subjective, Objective, Assessment and Plan) refers to the most common note-taking format for many areas of medicine - chiropractic included. In this article, you can learn about the benefits of SOAP notes, information that they must contain, and how Healthie’s SOAP note software can help you write them effectively. Healthie’s practice management software is completely HIPAA- & PCI compliant. Learn more about our free account by clicking here.
What is the purpose of SOAP notes? ?
SOAP documentation has many benefits: it’s consistent, universal, and ensures you’re staying compliant with Medicare requirements. Chiropractic SOAP notes:
- Help you track your patients’ progress
- Make it easier to accurately code and bill for your services
- Will be easily understood by other healthcare professionals and medical administrative staff
- Keep you compliant; in the case of an audit, your SOAP notes will help you to prove that you correctly followed procedures
- Can be key evidence in a malpractice claim
- Provide the level of specificity that Medicare and other insurance providers require
Using chiropractic SOAP notes is particularly important when you’re treating patients covered by Medicare. Medicare has very detailed guidelines for how chiropractic notes must be taken, which you can review here. If you aren’t documenting correctly, you risk claims being rejected. Therefore, taking complete and correct SOAP notes ensures that you will get paid for your services. Healthie makes this process easy and smooth. To set up a free Starter account with Healthie today, click here.
What are the four parts of a SOAP note?
To write SOAP notes correctly, you must incorporate all four parts of the acronym: Subjective, Objective, Assessment, and Plan. Here is what you need to include within each section:
The Subjective part of the SOAP note details the patient’s first-hand report of their condition. Start off by including information about the primary issue that the patient is seeing you about, whether it’s neck pain, back pain, or something else.
For an initial Subjective note, make sure you include:
- The patient’s symptoms
- When the pain began
- How severe the pain is
- What makes the pain better, and what makes it worse
- If trauma was involved, and if so, details about the injury
- Any repetitive motions which may be contributing to the pain
- Information about the patient’s medical history
Follow-up Subjective notes should include information about:
- New symptoms
- Changes to existing symptoms
- If the patient’s pain has improved or deteriorated since their last appointment
- Which treatment and therapies have been effective, and which haven’t
The objective part of the SOAP note includes the measurable data that you have gathered about the patient. This may include:
- Findings from your physical examination, including information about the patient’s posture, gait, etc.
- Lab tests and results
- Medical imaging
Based on the Subjective and Objective information, you must then make an Assessment about the patient’s condition. This should include both a diagnosis and a prognosis.
After reviewing the data, you should be able to conclude what you think the problem is. In your follow-up notes, you can also state how the patient is responding to treatment and any changes to the diagnosis since you last met with them.
In the prognosis section, indicate your opinion about the likely course of the patient’s condition. Make sure that you note any factors which may impact their recovery, and add information about the patient’s short and long term rehabilitation goals.
The final part of a chiropractic SOAP note is the Plan. Here, you should outline what action you intend to take. This could include:
- Lab work that you have ordered
- Adjustments that you have performed, or intend to perform
- Any specialists that you have referred the patient to
- Treatments, therapies, exercises, and lifestyle changes that you have recommended
Use Healthie’s software to easily write chiropractic SOAP notes
Making sure your documentation is correct and complete can be time-consuming, but chiropractic SOAP note software can make all the difference. Healthie is a comprehensive EHR platform for chiropractors, offering:
- Built-in chiropractic SOAP note templates
- Forms you can easily customize to meet the unique needs of your practice
- The ability to take notes securely within the Healthie platform
- Integration with insurance billing tools
- HIPAA, PIPEDA, GDPR, and PCI-compliance - so all your information is kept secure
Simplify your chiropractic SOAP notes and try Healthie’s software today.
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