Chiropractic SOAP Notes Template with Examples

Updated: November 03, 2023

It’s no secret that clear communication and comprehensive documentation are essential in chiropractic care. They not only ensure that patients receive consistent care but also help with their legal and insurance claims.

Chiropractic SOAP notes have emerged as a standardized tool for documenting clinical encounters.

This article delves into chiropractic SOAP notes and provides template examples to enhance understanding.

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What is a Chiropractic SOAP Note?

Chiropractic SOAP notes are used by chiropractors to document clinical encounters. The term “SOAP” is an acronym representing four key sections:

1. S (Subjective): This section captures the patient’s complaints, symptoms, and feelings. It typically includes the patient’s description of pain, discomfort, or any other ailment they are experiencing.

2. O (Objective): Here, the chiropractor documents their observations, including the results from physical examinations, tests, or any measurable outcomes.

3. A (Assessment): This segment involves the chiropractor’s diagnosis or professional opinion on the patient’s condition, based on the information gathered from the first two sections.

4. P (Plan): This part details the recommended treatment, exercises, or any other therapeutic procedures the chiropractor intends to carry out.

Chiropractic SOAP Note Template

A properly formatted SOAP note ensures chiropractors accurately capture essential patient information. Below is a dedicated template tailored for chiropractic needs, capturing every detail of the patient’s visit:

Chiropractic SOAP Note Template Copy Snippet Copied!

Patient Information:
Name: ___________________________________________
Date of Visit: _______________ Time: ____________
Date of Birth: _______________ Age: ____________
Referring Physician (if any): _______________________

S (Subjective)
Chief Complaint: [Description of the problem in the patient’s words.]
History of Present Illness: [Duration, onset, and any related events.]
Pain Description (if applicable): [Location, type (e.g., sharp, dull), frequency, severity (1-10 scale).]

O (Objective)
Physical Examination:
Posture: ____________________________
Palpation: ____________________________
Range of Motion: ____________________________
Special Tests (if conducted): ____________________________

Additional notes on physical findings:
Diagnostic Studies (X-rays, MRIs, etc.): Results or findings.

A (Assessment)
Primary Diagnosis:
Differential Diagnoses (if considered):

P (Plan)
Treatment Plan: Chiropractic adjustments, modalities, therapies.
Home Care Recommendations: Exercises, ice/heat, rest, etc.

Follow-up: When and what will be assessed in the next visit.

This template can be printed or integrated into digital platforms for easy use. It can also be modified to fit specific requirements or preferences of individual practices.

Chiropractic SOAP Note Examples

Here are three examples to illustrate what a well-documented SOAP note looks like:

Example 1

Patient Information:

Name: John Doe
Date of Visit: 10/26/2023 Time: 10:00 AM
Date of Birth: 01/15/1980 Age: 43
Referring Physician (if any): Dr. Smith

S (Subjective)

  • Chief Complaint: Lower back pain after lifting a heavy box.
  • History of Present Illness: Pain began two days ago, immediately after lifting. No prior history of similar pain.
  • Pain Description: Located in the lumbar region, sharp pain, intermittent, 7/10.

O (Objective)

Physical Examination:

  • Posture: Anterior pelvic tilt noticed.
  • Palpation: Tenderness over L4-L5 region.
  • Range of Motion: Limited lumbar flexion due to pain.
  • Special Tests: Positive straight leg raise test on the left.
  • Diagnostic Studies: None conducted.

A (Assessment)

  • Primary Diagnosis: Lumbar strain.
    Differential
  • Diagnoses: Disc herniation, sciatica.

P (Plan)

  • Treatment Plan: Lumbar spinal adjustments and cold compress.
  • Home Care Recommendations: Avoid heavy lifting, apply ice 20 minutes every 2 hours.
  • Follow-up: In one week for reassessment.
Example 2

Patient Information:

Name: Jane Smith
Date of Visit: 10/27/2023 Time: 2:00 PM
Date of Birth: 06/25/1990 Age: 33
Referring Physician (if any): Dr. Harper

S (Subjective)

  • Chief Complaint: Persistent neck stiffness since last week.
  • History of Present Illness: Woke up with stiffness, possibly due to sleeping posture. No improvement over the week.
  • Pain Description: Upper cervical area, dull ache, constant, 4/10.

O (Objective)

Physical Examination:

  • Posture: Forward head posture observed.
  • Palpation: Muscular tightness in the cervical paraspinal region.
  • Range of Motion: Reduced cervical rotation bilaterally.
  • Special Tests: None conducted.
  • Diagnostic Studies: None conducted.

A (Assessment)

  • Primary Diagnosis: Cervicalgia.
  • Differential Diagnoses: Cervical radiculopathy, tension-type headache.

P (Plan)

  • Treatment Plan: Cervical adjustments and deep tissue massage.
  • Home Care Recommendations: Neck stretching exercises and use of a cervical pillow.
  • Follow-up: In five days for progress check.
Example 3

Patient Information:

Name: Robert Johnson
Date of Visit: 10/28/2023 Time: 11:30 AM
Date of Birth: 09/12/1975 Age: 48
Referring Physician (if any): Dr. Martinez

S (Subjective)

  • Chief Complaint: Tingling and numbness in the right hand.
  • History of Present Illness: Symptoms started gradually over a month. No known trauma. Feels more prominent in the thumb and first two fingers.
  • Pain Description: No pain, just a consistent tingling sensation.

O (Objective)

Physical Examination:

  • Posture: Normal.
    Palpation: No tenderness in the cervical region.
  • Range of Motion: Full cervical range without discomfort.
  • Special Tests: Positive Phalen’s test.
  • Diagnostic Studies: None conducted.

A (Assessment)

  • Primary Diagnosis: Carpal Tunnel Syndrome.
  • Differential Diagnoses: Cervical radiculopathy, peripheral neuropathy.

P (Plan)

  • Treatment Plan: Wrist mobilizations, ultrasound therapy.
  • Home Care Recommendations: Wrist splinting at night, carpal tunnel exercises.
  • Follow-up: In two weeks to assess symptom progression.

Accurate and standardized documentation stands as the backbone of effective chiropractic care. Accordingly, Chiropractic SOAP notes serve as a pivotal tool, ensuring a holistic, structured, and consistent approach to patient documentation. With SOAP notes, chiropractors can refine their record-keeping practices, positioning themselves not merely for compliance but also for excellence in patient care.

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Patient Information: <br>Name: ___________________________________________ <br>Date of Visit: _______________ Time: ____________ <br>Date of Birth: _______________ Age: ____________ <br>Referring Physician (if any): _______________________ <br> <br>S (Subjective) <br>Chief Complaint: [Description of the problem in the patient's words.] <br>History of Present Illness: [Duration, onset, and any related events.] <br>Pain Description (if applicable): [Location, type (e.g., sharp, dull), frequency, severity (1-10 scale).] <br> <br>O (Objective) <br>Physical Examination: <br>Posture: ____________________________ <br>Palpation: ____________________________ <br>Range of Motion: ____________________________ <br>Special Tests (if conducted): ____________________________ <br> <br>Additional notes on physical findings: <br>Diagnostic Studies (X-rays, MRIs, etc.): Results or findings. <br> <br>A (Assessment) <br>Primary Diagnosis: <br>Differential Diagnoses (if considered): <br> <br>P (Plan) <br>Treatment Plan: Chiropractic adjustments, modalities, therapies. <br>Home Care Recommendations: Exercises, ice/heat, rest, etc. <br> <br>Follow-up: When and what will be assessed in the next visit.
Patient Information: <br>Name: John Doe <br>Date of Visit: 10/26/2023 Time: 10:00 AM <br>Date of Birth: 01/15/1980 Age: 43 <br>Referring Physician (if any): Dr. Smith <br> <br>S (Subjective) <br>- Chief Complaint: Lower back pain after lifting a heavy box. <br>- History of Present Illness: Pain began two days ago, immediately after lifting. No prior history of similar pain. <br>- Pain Description: Located in the lumbar region, sharp pain, intermittent, 7/10. <br> <br>O (Objective) <br>Physical Examination: <br>- Posture: Anterior pelvic tilt noticed. <br>- Palpation: Tenderness over L4-L5 region. <br>- Range of Motion: Limited lumbar flexion due to pain. <br>- Special Tests: Positive straight leg raise test on the left. <br>- Diagnostic Studies: None conducted. <br> <br>A (Assessment) <br>- Primary Diagnosis: Lumbar strain. <br>- Differential Diagnoses: Disc herniation, sciatica. <br> <br>P (Plan) <br>- Treatment Plan: Lumbar spinal adjustments and cold compress. <br>- Home Care Recommendations: Avoid heavy lifting, apply ice 20 minutes every 2 hours. <br>- Follow-up: In one week for reassessment.
Patient Information: <br>Name: Jane Smith <br>Date of Visit: 10/27/2023 Time: 2:00 PM <br>Date of Birth: 06/25/1990 Age: 33 <br>Referring Physician (if any): Dr. Harper <br> <br>S (Subjective) <br>- Chief Complaint: Persistent neck stiffness since last week. <br>- History of Present Illness: Woke up with stiffness, possibly due to sleeping posture. No improvement over the week. <br>- Pain Description: Upper cervical area, dull ache, constant, 4/10. <br> <br>O (Objective) <br>Physical Examination: <br>- Posture: Forward head posture observed. <br>- Palpation: Muscular tightness in the cervical paraspinal region. <br>- Range of Motion: Reduced cervical rotation bilaterally. <br>- Special Tests: None conducted. <br>- Diagnostic Studies: None conducted. <br> <br>A (Assessment) <br>- Primary Diagnosis: Cervicalgia. <br>- Differential Diagnoses: Cervical radiculopathy, tension-type headache. <br> <br>P (Plan) <br>- Treatment Plan: Cervical adjustments and deep tissue massage. <br>- Home Care Recommendations: Neck stretching exercises and use of a cervical pillow. <br>- Follow-up: In five days for progress check.
Patient Information: <br>Name: Robert Johnson <br>Date of Visit: 10/28/2023 Time: 11:30 AM <br>Date of Birth: 09/12/1975 Age: 48 <br>Referring Physician (if any): Dr. Martinez <br> <br>S (Subjective) <br>- Chief Complaint: Tingling and numbness in the right hand. <br>- History of Present Illness: Symptoms started gradually over a month. No known trauma. Feels more prominent in the thumb and first two fingers. <br>- Pain Description: No pain, just a consistent tingling sensation. <br> <br>O (Objective) <br>Physical Examination: <br>- Posture: Normal. <br>- Palpation: No tenderness in the cervical region. <br>- Range of Motion: Full cervical range without discomfort. <br>- Special Tests: Positive Phalen's test. <br>- Diagnostic Studies: None conducted. <br> <br>A (Assessment) <br>- Primary Diagnosis: Carpal Tunnel Syndrome. <br>- Differential Diagnoses: Cervical radiculopathy, peripheral neuropathy. <br> <br>P (Plan) <br>- Treatment Plan: Wrist mobilizations, ultrasound therapy. <br>- Home Care Recommendations: Wrist splinting at night, carpal tunnel exercises. <br>- Follow-up: In two weeks to assess symptom progression.

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