What’s in a Soap Note-
You already know what a basic S.O.A.P.
needs to have (what hurts, what do you think, what are you going
to do to fix it and when to come back). You also have at least a
minimum understanding of
documentation, however if we put 5 Chiropractors in a
room and ask more specifically about what needs to be in the
Subjective part of the note , we would likely come away with 5
This tells us that there is quite a bit of
confusion and misinformation on what specifically needs to be in
your soap note for patient encounters. Proper documentation is
needed for proper caring for your patients, protecting yourself
from audits and malpractice law suits. While the later is rare,
it still happens. Ask your malpractice rep if documentation is a
major factor in their cases.
The Subjective is one of the easier parts
of documenting. To simplify: Why is the patient coming to see
you? Now don’t get me wrong, writing just LBP or NP isn’t going
to cut it.
Let’s start with an example of a proper
documented Subjective complaint:
Alex came in today complaining of neck pain
that started on 7/1/2010. He said, "I
woke up with a stiff neck last Sunday". The symptoms are
bilateral with moderate pain occurring frequently (51-75% of the
day). He describes the pain as sharp and stabbing with radiating
pain to his right shoulder. Ice and heat do improve the pain
although the pain has remained about the same since onset and
pain is rated at a 5 on a 1-10 scale (0 being no pain and 10
being excruciating). Pain is aggravated by turning his head from
side to side and bending over.
In breaking this
down we are covering all of the basics. You may have learned the
O.P.Q.R.S.T. acronym when you were in school or at a seminar.
This is a great model to stick with and actually documents above
and beyond the minimum requirements.
When did the pain begin?
Provokes- What makes the main worse?
Quality- Describe in the patient’s words what kind of pain they
Radiates- Does the pain radiate to a body part?
Severity- What kind of pain level are we talking about?
When did the pain start and how long has patient had condition?
Using this model
is very strong. Medical documentation related to proper E&M
coding requires 4 components of the HPI (History of Present
Illness) be documented during the initial exam. As you can see,
the above model covers 6 of them.
The same process
needs to be done for all major complaints. If you prefer to
treat them all at once, your initial exam and intake process
will be lengthy. Another idea you may consider is to treat only
1 major condition at a time and when one complaint is at a
satisfactory level for the patient, you then address the next
item on their list. This reduces the documentation burden per
visit and allows you and the patient to focus on one item at a
The history of
this condition should be taken by the doctor directly. Staff
does not have the proper training to recognize a risk factor so
a doctor should do this portion of intake with the patient.
This is something you should keep in mind.
My goal with this lesson will be to show
what basic aspects of the visit should clearly be documented.
Anything additional you would like to include is typically
alright, however I caution you to be careful when documenting
exams which are not widely accepted and understood by all
flavors of healthcare.
Objective exam can consist of many types of testing and
retesting to check for differences and improvements. In this
lesson I am focusing on what exams to check in a typical follow
This is a difficult lesson to teach because
everyone does exams and follow-ups differently.
I will attempt to stick with the general approach to
Objective exam. Objective exam is also difficult because there
is no cut and dry number of items you must document to be
compliant. Essentially it is very subjective since some could
say simply listing ‘cervical shows stiffness’ would be the same
as ‘C1, C2 and C3 on the right show stiffness today’.
Generally speaking we want to be consistent
with the items we check and document here. If a patient has neck
pain, we want to check ROM, swelling, stiffness, muscle tension,
etc. We also want to make notes of differences for each visit
and approach the documentation slightly different each time. The
nature of Chiropractic is repetitive, however your job is to
change this up so you don’t have 10 soap notes that all look
like this: Swelling and stiffness in C1, C2 – The end.
Keep in mind that every day your notes
should show medical necessity for the services you provide.
There are some gray areas and you can push the envelope on extra
services, however, those of you that do this often should pay
extra attention to the medical necessity side of your
I want you to take away that Medicare wants
you to check muscle findings along with your typical segmental
areas checked. The choice is yours of course; however, briefly
discussing muscles found close to a problem area of the spine is
a quick and easy way to expand this area of your daily notes and
improve your documentation.
Let’s see an example of a proper documented
Objective below. Keep in mind I am covering just a standard
follow up visit as we will cover initial exam findings in
and hypertonicity were found in the upper cervical region
(specifically C2 and C3 on the right side). Swelling, tautness
and tenderness were also noted in right C2, C3. Motion palpable
fixation, muscle spasm, weakness was found in left trapezoid
The daily Objective doesn’t have to be
complicated. The challenge, as I already hit on, is how does
this compare side by side against the 10 or 20 follow up visits
you have between the exams? Do they all say the same thing? Are
they simply a copy of the prior note? In the software notes
world this can sometimes happen automatically for speed,
however, you MUST change every day’s visit objective so they are
The days of better/same/worse are gone
folks. We can no longer get by with the basics and this includes
the daily assessment. What needs to be documented in order to
show medical necessity in the assessment? Let’s find out.
Here is an example of a well
documented daily assessment:
- Lumbar Subluxation (839.20)
- Dizziness, vertigo (780.4)
- Headache (784.0)
- Neck pain (723.1)
After today's assessment Alex’s
overall condition is progressing slow, but steady.
Patient's progress is noted as evidence by decreasing
pain and increased ROM in the cervical region. Additionally Alex
neck spasms and swelling are reduced.
Low Back Pain: Low back pain has been
aggravated because of working longer hours on the line at work
Your assessment must contain the information below every time
you see the patient:
- General daily assessment.
- Per complaint daily assessment.
I call these daily assessments because you need to
change/update them each time you see the patient.
Remember the general and per complaint assessments shouldn’t be
the same for every note in the patient file. Yes, changing these
each time is a pain when you just saw the patient 2 days ago,
however, it is the right thing to do if you want to be as
compliant as possible. You need to setup your forms or software
to make these quick changes. For example you should be able to
change each assessment in less than 5 seconds. For my example
above you would spend less than 15 seconds changing your
assessment. Let’s say you see 30 patients, so it could equal 7
minutes of your time.
Now if I can help you get all your notes for that day done in
just 35 minutes, I think I would make your Christmas card list.
Am I right? It can be
done, however, you have to remove the extra fluff and get just
the facts on progress. We will put these lessons together to
share how you can accomplish a great note in less time.
The procedure section of your daily soap is
very simple. Don’t over think or over document. It only confuses
the issue and makes a trained reviewer roll their eyes when they
see a paragraph explaining how great Electrical Stimulation is
for healing a sprained low back.
There is a lot of confusion on what must be
documented per procedure performed. Your procedures should
simply be a cut and dry list of what was performed with the
patient during their office visit. There is no reason to write a
book about the success or validity of a specific procedure. It
simply boils down to what you already probably know.
Here are a few things to consider about
documenting procedures (in no particular order):
insurance commonly pay for this type of procedure, and are
you using the code that you should be?
your subjective and objective note prove that the location
you are doing the procedure on is valid?
you doing more procedures than really needed for this visit?
Let me break down each point above.
First, does insurance commonly pay for an
item? This one is pretty common sense, but if insurance doesn’t
pay for a laser treatment for fertility, then why try to get
them to pay you?
Second, are you using the proper code? This
is important because if you are trying to bill low level laser
as a neuromuscular or manual therapy code, you are just asking
for trouble. Make sure you are using the right code, and if
there is no code, you should be billing as a cash procedure
directly to the patient and not submitting this to insurance.
Third, the rest of your note should backup
what you are doing. Your Objective section needs to mention pain
or discomfort in every area if you are documenting that you did
a procedure on it. A most basic medical documentation example is
that if you do a strep test, you better have ‘my throat hurts’
as a subjective complaint. I like to use medical documentation
examples as much as I can because in Chiropractic we seem to
document completely different, and we shouldn’t. Do you think
you would see a detailed description of why a strep test was
performed in a medical note? Nope, this would be assumed that
anyone in medical field or insurance can look up the test if
they are questioning it.
Last, are you doing more than you should be
doing for the patient? Let’s talk about someone going into an
Emergency room. The most important thing is to find out what the
problem is ASAP. That is why we spend a quick $1,000 and learn
we were just dehydrated and we can return home. Stick with this
idea for a moment because it applies to your patients as well.
When the patient first comes in, that is when it is more
‘acceptable’ to run the most tests and have the highest patient
It makes “insurance sense” to focus on just
one major complaint at a time.
This will of course reduce your per visit number of
procedures, however, it will be more likely to get paid and will
extend your patient life span of visits to your practice.
Below is an example of a simple, yet
well documented daily procedures section. Keep in mind the title
of your section really doesn’t matter. It could be daily
treatments, treatments today, treatments, procedures, etc.
CMT 1‑2 Spinal Regions (98940)
was performed on thoracic and lumbar regions.
Neuromuscular Reeducation (97110)
for 8 to 15 minutes was performed on the thoracic and lumbar
Remember, keep it simple for procedures!
The plan section of your daily soap
consists of quite a few components (or it should contain a
number of important aspects). Years
ago a plan was likely to just read “return as needed” with no
more details. Now that just doesn’t meet documentation
While your plan doesn’t have to be
complicated, it does need to have a few parts to it:
- How often are we seeing them and what are we doing?
- Are we doing any home therapies or home instructions?
- What are the goals for improvement (this one is a big one
Ensure you cover 1 & 3 for your plan.
Below is good example of how to
quickly cover all three.
manipulation to lumbar spine 2x times per week for 3-6 weeks.
packs to lumbar region as needed to reduce swelling and improve
To continue the use of cold and
heat and the proper application of alternating cold/heat as
needed for lumbar pain.
Short Term Goals
Improving low back pain to
improve ability to do housework and go shopping 50% within 10
Your assessment is where you cover your true functional
improvements; however your plan should contain the goals that
match the things you are also documenting in your assessment.
Make sure to match up plan items to the given condition when you
are working with more than one condition. For example, if you
are doing electrical stimulation for the low back, make sure you
indicate that in your plan. If you just have one primary
condition, this is not critical since a reviewer can see that
you just have neck pain or LBP or a single condition.
Remember: plan your work and work your plan. Without a good plan
your entire span of patient visits could be in jeopardy if you
were to have them audited.
In our next lesson we will cover exams.
Then I will tackle re-exams, follow ups,
and new conditions.
Please stay tuned!
Author, Alex Niswander, is a soap notes
expert with over 10 years focusing on clinical charting and
proper noting procedures.
He has reviewed charts in hundreds of clinics throughout
the country and continually reviews new requirements by Medicare
and major insurance carriers.
To learn more about Alex’s products, please
visit the company website:
Chiro QuickCharts - billing/scheduling/ehr/emr