SOAP NOTES
 
   

SOAP Notes

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:
  Frankp@chiro.org


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SOAP Note Forms   (Acrobat PDF format)
Side A   and   Side B
This 2-sided form is designed for a file attachment on the 11" side, so there is a 1 inch border on the left. The tables at the right side are for listing leg length findings, incidental findings (thermography, palpatory) and the segments adjusted, and their “listings”. If you adopt these forms, please! don't forget to remove the header, which lists my office name, at the top of the form.


Writing a S.O.A.P. Note
New York Chiropractic College Guidelines (Acrobat PDF format ~ 6 pages)

Progress notes are the chronological record of the patient’s presentation, treatment, and response to care, as well as a record of any telephone conversations with patients and notations on missed appointments. The system utilized to record patient progress/office visits involves notations pertaining to current subjective data, objective data, assessment, and procedures done on that day and plans for further management (SOAP).


Maximizing the Effectiveness and Efficiency of Clinical Documentation
Best Practices in Clinical Chiropractic
~ FULL TEXT
This Full-Text from the TICC collection Best Practices in Clinical Chiropractic outlines efficient charting methods and supplies valuable forms to improve your charting efficiency. Our thanks to Aspen Publishers and Robert Mootz, D.C. for releasing this article, exclusively at Chiro.Org!


The Documentation Section
Our Documentation Section @ Chiro.Org is devoted to a full description of what is considered “complete” patient file documentation by the Chiropractic Schools, National Associations, and Third Party payors.



Keep Your Records Clean With SOAP
ACA News ~ November 2013

There are many systems used by health care professionals to track patients’ progress, but SOAP is probably the most common format for maintaining progress notes. Using SOAP to keep clear, complete, concise, accurate, patient- and encounter- specific records is not just for medical doctors. It’s one of the best ways for the doctor of chiropractic to monitor patients’ progress, as well as to maintain complete records that can be used as a defense in third-party audits or malpractice suits.


SOAP Notes: Is It Time for a Cleaning?
Dynamic Chiropractic – May 15, 2013

I have been planning for some time to write an article about how traditional SOAP notes do not fit chiropractic practice, and the unfairness of holding DCs to a model clearly created for and primarily applicable to medical physicians. But Dr. Ronald Short beat me to the punch with his outstanding article: “SOAP: A Chiropractic Perspective” [March 1, 2013 issue], in which he masterfully illustrated the problem. Hopefully, claim reviewers and documentation gurus will finally realize the difference between a chiropractic “assessment” visit and a chiropractic “treatment” visit.


SOAP Notes:   A Chiropractic Perspective
Dynamic Chiropractic ~ March 1, 2013

The important thing to remember regarding the SOAP is that it was designed for the practice style of a medical doctor. To illustrate this, let's assume a scenario. You are working in your garden, clearing under a rose bush, when you are startled by a small snake. You reflexively jerk your arm back and cut your forearm on one of those monstrous thorns that reside at the base of the rose bush. You now are the proud owner of a 4-inch gash on your forearm. You know you should go inside, and clean and bandage it, but you are nearly done and it is getting dark, so you blot it with a towel (that isn't too dirty) and keep working.


The “Perfect” SOAP Note: A Chiropractic Holy Grail
Dynamic Chiropractic – February 26, 2010

As promised, here is the bad news: I will not reveal for you the "perfect" SOAP note that you can copy and use for every one of your patients. Here's why: The purpose of a SOAP note (or any documentation) is to communicate what is going on with your patient to someone (like an insurance company) who is not there. While there are certain elements that should be part of every good SOAP note, it also should be a document flexible enough to change with the patient. For example, if you have three patients, all have neck pain, one is 5, one is 35 and one is 85, shouldn't something about their documentation look different, even if they have the same presenting problem?


What is Medical Necessity?
A Chiro.Org Editorial ~ August 17, 2009

“There are almost as many definitions of medical necessity as there are payors, laws and courts to interpret them. Generally speaking, though, most definitions incorporate the principle of providing services which are "reasonable and necessary" or "appropriate" in light of clinical standards of practice. The lack of objectivity inherent in these terms often leads to widely varying interpretations by physicians and payors, which, in turn, can result in the care provided not meeting the definition.”



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