Ask any doctor what part of the job they dislike the most, and they will probably respond that it’s the paperwork. However, SOAP notes in particular are extremely important for any medical practice, and a chiropractic office is no exception. Here are some things to keep in mind as you’re filling out this vital document.
Importance of SOAP Notes
Writing a good chiropractic SOAP note is important for three main reasons:
- Patient treatment notes are required by law.
- Good quality SOAP notes will protect you in case of a lawsuit.
- Detailed SOAP notes will help you to provide better care for your patients.
Subjective Information
Make note of all the information a patient tells you about how they’re feeling, regardless of whether it seems related directly to their main complaint. As you continue to work with them, secondary issues may become more prominent, and this way you will have a track record already started. In addition, sometimes patients forget that they were having a particular problem and it’s helpful if you can have it in your notes to check in on it. Also, there are times when a patient will question if a physical problem they’re experiencing could have been caused by their chiropractic treatment, so it’s helpful to have pre-existing issues well documented.
Objective Information
In addition to making note of the results of any testing that you do, this is a place to make note of anything else you notice in the patient such as inflammation, discoloration, sensitivity, muscle tension, and any seeming incongruities. As time goes on, these can offer clues as to potential underlying conditions or problems that were just beginning to develop, helping you to better diagnose and treat your patient.
Assessment Section
Assessing the subjective and objective information will help lead you to a diagnosis. It’s important in this section to remember that, while you should still take thorough notes on all the details that come up in your consultation and exam, your primary diagnosis needs to relate to the main complaint that the patient is seeing you for. For example, if someone comes to you for a workman’s compensation or motor vehicle accident claim because of neck pain, your primary diagnosis will be related to that, regardless if you feel that the person’s anxiety is actually causing greater problems in their life.
Plan for Treatment
Your patients are trusting you to come with a viable plan to help them resolve their health problem. In addition to recommending a certain number of treatments per week for so many weeks, this can also include supplements, diagnostic tests, exercises, diet, and lifestyle advice. Having a thorough treatment plan can help the patient to feel better mentally and emotionally about the chances that they will get relief. Your patients will not know what is appropriate in terms of when to come back if you don’t tell them.
Timely Documentation
If you have a busy practice, it can be hard finding the time in the day to fill out your SOAP notes properly. However, the sooner you do so after seeing the person, the less likely that you will end up forgetting to add something.
Record Accessibility
Once you’ve got your patient file going, you will want to establish a system so that the records are easily accessible each time that you see the person. This can be done either by holding on to paper files or having an electronic system. Electronic systems include those that are actually filled out on a computer as well as those in which records are scanned in and organized into files.
When you’re studying and working in your school clinic, you learn to take detailed SOAP notes. But once you get out into the real world and have a busy practice, it’s easy to fall behind on notes in an effort to catch up with treatments. With the right system in place, however, there’s no excuse for no keeping quality patient notes.