Initially known as a problem-oriented medical record (POMR), healthcare professionals across multiple disciplines utilize SOAP notes to organize and document their findings objectively. While the specific details and length of SOAP notes will vary by discipline, the notes follow a similar basic structure.
SOAP refers to Subjective, Objective, Assessment, and Plan. Learning to write SOAP notes is crucial since the standardization of notes makes it easier for healthcare providers in other disciplines to understand the information in a glimpse, promoting easy patient coordination when needed.
Let’s look at how to create SOAP notes for chiropractors.
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Get Chiropractic Software With SOAP Notes for Chiropractors
One of the easiest ways to write great SOAP notes for chiropractors is using the right chiropractic software. You can use the built-in SOAP templates on the Chiro8000 platform to access and fill out SOAP notes after a session quickly.
Chiropractic software makes it much easier to organize and minimize the paperwork. You can also download the SOAP templates on Chiro8000 software and keep them in hand during sessions. Let’s look at how to use each segment on the template.
Breaking Down Soap Notes
SOAP notes help you write critical information about each patient quickly, clearly, and organized. The best way to write SOAP notes for chiropractors is to use Chiro8000 software is to know exactly what you should write on the different segments:
The first segment on chiro software SOAP templates is for reporting how the patient said they were feeling. It’s about their symptoms. You can also include information gathered by the family members and a review of past medical records.
The main concern in this section is the ‘chief complaint’ (CC), the main problem they’re presenting. Even when a patient has multiple CCs, identifying the most pressing issue will lead to an adequate diagnosis.
Here are some questions to help uncover your patient’s Chief Complaint:
- Thoroughly explain your symptoms and how long they have lasted
- How severe are the symptoms, and what makes them subside or worse
- What is your medical history
- Are you taking medicine?
The next segment on soap notes for chiropractors should consist of the physical findings you gather. Include the vital signs, information from any other specialist, medical records, and the patient’s appearance, mood, and behavior during the session.
The section must be objective, meaning it should only consist of the factual information observed, not what the patient says.
The assessment section utilizes what you gathered in the objective and subjective sections. Use this segment on your Chiro software template to describe what you have concluded is wrong with the patient.
Like the name, it’s an assessment. Include your interpretation of all the information in previous sections, then draw from your professional knowledge. You can name a potential diagnosis for the condition.
If this is their second or consecutive visit, use this segment to comment on the progress since the last session.
The plan is the last section on the Chiro8000 SOAP template. It outlines your plan for the next step in treating the patient. It can include long and short-term goals for the patient. Be as detailed and specific as possible about what you plan to work on during their next session. Write down what you expect to see in the patient during their treatment plan.
Elevate Your Practice With SOAP Notes Software
Order and organization lie at the heartbeat of any successful health company. Patient records are crucial to the patient’s treatment and healing journey. Good chiropractic software should make this process easier for staff to manage. Follow SOAP guidelines and regularly update the software to maintain order and precision in practice for seamless patient experiences.