How to Write Chiropractic SOAP Notes: Examples and Templates

Key Takeaways

• SOAP notes help chiropractors track patient progress, support clinical decisions, and meet compliance standards.
• Each note should include subjective input, objective findings, clinical assessment, and a plan for care.
• Incomplete or unclear documentation can lead to denied claims and audit risk.
• Using templates, macros, and structured workflows saves time and improves consistency. ‍
• ChiroSpring simplifies documentation with customizable templates, smart automation, and built-in tools that speed up note-taking.

Keeping up with chiropractic SOAP notes can feel like a time sink, especially when your schedule’s already full. But accurate, consistent documentation isn’t just busywork. It protects your license, improves patient care, and helps you get paid.  

Below, we’ll break down how to write better chiropractic SOAP notes with examples and easy-to-follow tips.

What Are SOAP Notes?

SOAP notes are a structured way to document each patient visit. The format includes four sections: Subjective, Objective, Assessment, and Plan. It keeps records organized, consistent, and easy to review across providers.

In chiropractic care, they help you document clearly and make informed decisions without losing sight of patient progress.

Why Detail Matters in Chiropractic Documentation

You don’t just write SOAP notes for the visit in front of you. You write them so you know exactly what happened last time and what needs to happen next.

When documentation lacks detail, it creates confusion. It’s harder to track progress or explain your decisions. And if the plan isn’t clear, it opens the door to claim denials and unnecessary scrutiny.

In fact, one chiropractic office was ordered to repay more than $300,000 after an audit found over half of its Medicare claims didn’t meet documentation requirements. That means the issue wasn’t fraud; it was incomplete records. When SOAP notes leave out the clinical reasoning behind your care, payers assume it wasn’t medically necessary.

Accurate notes give you the context to make decisions and the proof to stand by them.

Breaking Down Chiropractic S-O-A-P Notes

SOAP notes follow a standard format, but how you fill them out depends on your specialty. For chiropractors, the goal is to track musculoskeletal complaints clearly and support each visit with the right level of clinical detail. Here's how to approach each section.

Subjective (S)

The subjective section captures the patient’s own description of their symptoms. It covers the location, intensity, and quality of pain, along with any changes since the last visit. You might also include aggravating or relieving factors, relevant history, or functional limitations.

Example:
Patient reports lower back pain radiating into the left leg. Pain worsens after sitting and improves with light walking. Reports stiffness in the morning but no numbness or weakness.

Objective (O)

The objective section covers what you confirm during the exam. That includes your posture assessment, range of motion testing, palpation findings, orthopedic and neurological test results, and any relevant vitals. This part of the note should be clear, repeatable, and based only on what you observed.

Example:
Palpation reveals hypertonicity in lumbar paraspinals. L4/L5 restriction noted. Positive straight leg raise on left at 45 degrees. Lumbar flexion limited with pain.

Assessment (A)

Here, you interpret the subjective and objective findings. Use it to show your clinical reasoning and track whether the condition is improving, stable, or worsening.

Example:
Findings consistent with lumbar disc involvement causing radicular symptoms. Symptoms moderately improved since last visit. Functional limitations remain.

Plan (P)

The plan outlines what you did during the visit and what you’ll do moving forward. It includes adjustments, modalities, home exercises, and education. It should also indicate frequency and duration of care.

Example:
Performed spinal adjustments to L4/L5. Applied moist heat and myofascial release to lumbar region. Instructed patient on modified stretches. Plan to continue treatment 2x/week for 2 weeks, then reassess.

Examples of SOAP Notes for Chiropractic Conditions

Example 1: Acute Lumbar Strain

Subjective (S):
34-year-old male presents with low back pain after lifting at work yesterday. Pain localized to right lumbar region. Describes pain as sharp, worsened by bending and prolonged standing. Denies leg symptoms or recent trauma. No history of similar episodes.

Objective (O):
Antalgic posture observed. Palpation reveals tenderness and tightness in right lumbar paraspinals. Lumbar flexion and extension restricted with pain. Straight leg raise negative. Neurological exam unremarkable.

Assessment (A):
Acute lumbar strain. Findings consistent with soft tissue injury without signs of disc involvement or radiculopathy.

Plan (P):
Spinal manipulation to L3–L5. Applied cryotherapy post-treatment. Instructed patient on modified activity and home stretching. Treat 2x/week for 2 weeks, then reassess pain and mobility.

Example 2: Cervicogenic Headache

Subjective (S):
39-year-old female presents with right-sided headache and neck stiffness. Reports onset two weeks ago following increased screen time at work. Describes headache as steady and achy, starting at the base of the skull and radiating toward the temple. Symptoms worsen with desk work and improve slightly with movement. No nausea, photophobia, or history of migraines.

Objective (O):
Decreased cervical rotation and lateral flexion to the right. Palpation reveals tenderness in right suboccipital and upper trapezius regions. Forward head posture observed. Neurological exam normal.

Assessment (A):
Cervicogenic headache, right-sided, related to cervical joint dysfunction and muscular tension. No signs of migraine or neurological involvement.

Plan (P):
Cervical manipulation focused on C1–C3. Soft tissue release to suboccipital and upper trap. Instructed on posture correction and workstation setup. Prescribed neck mobility drills. Treat 2x/week for 2 weeks, then reassess frequency and intensity of symptoms.

Example 3: Thoracic Outlet Syndrome

Subjective (S):
42-year-old male reports numbness and heaviness in left arm after driving or reaching overhead. Symptoms began gradually over the past month and are now occurring daily. Describes intermittent hand weakness when working overhead. Denies recent injury, neck pain, or prior episodes.

Objective (O):
Left shoulder slightly depressed with forward rounding. Palpation reveals tension in scalene and pec minor. Positive costoclavicular and Roos tests on left. No sensory or motor deficits on neuro exam. Cervical ROM full and symptom-free.

Assessment (A):
Thoracic outlet syndrome, left-sided. Likely vascular-neurogenic compression due to postural mechanics and soft tissue involvement.

Plan (P):
Performed soft tissue mobilization to scalene and pec minor. Instructed on postural bracing and positional modifications during work. Prescribed shoulder retraction and mobility exercises. Treat 2x/week for 3 weeks, then reassess symptom frequency and endurance tolerance.

The Benefits of Using a SOAP Notes Template

Whether you create your own or use the built-in options in ChiroSpring, a strong SOAP note template gives you structure without slowing you down. It keeps your documentation focused, consistent, and aligned with both clinical and billing needs.

1. Streamlined Billing

ChiroSpring automatically generates claims based on completed SOAP notes. Features like advanced claim scrubbing, auto-posted ERAs, and built-in clearinghouse support help reduce denials and get you paid faster.

2. Less Time on Documentation

With pre-loaded templates and customizable macros, you can finish notes in seconds without sacrificing quality. That gives you more time to focus on patients, not paperwork.

3. Audit-Ready Records

Templates guide you to include all required details, helping your documentation stand up to audits or record requests. Every note clearly reflects the care you provided.

4. Consistent Clinical Communication

Whether you’re collaborating with a biller or another provider, templates ensure the information is clear and easy to follow.

Tips for Writing SOAP Notes Faster (Without Losing Accuracy)

Even experienced chiropractors can find SOAP notes time-consuming. But with a few adjustments, you can document more efficiently while keeping your notes clear, complete, and compliant.

1. Start With a Template, Not a Blank Page

Use a preloaded template to speed up your workflow and make sure nothing gets missed. ChiroSpring offers over 50 templates you can customize to fit how you work.

2. Use Macros for Repeatable Phrasing

If you find yourself typing the same sentences over and over, set up SOAP macros. With one click, you can insert full sentences or paragraphs and keep things moving.

3. Dictate When You’re on the Move

ChiroSpring supports voice dictation, so you can speak your notes instead of typing them. It’s especially helpful when juggling a full schedule.

4. Auto-populate Based on Last Visit

For return patients, you don’t need to start from scratch. Just open the previous note, update what’s changed, and get back to care.

5. Customize Templates Around Your Workflow

Use drag-and-drop editing, smart fields, and body diagrams to create templates that match how you practice. They're fast, familiar, and easy to update.

How ChiroSpring Simplifies Chiropractic Documentation

You don’t have hours to spend on notes, but you can’t afford to cut corners either. Clear, detailed documentation keeps care moving, protects your decisions, and helps ensure clean claims.

ChiroSpring makes SOAP notes faster to complete and easier to manage, all from one place.

• 50+ templates tailored for chiropractic workflows
• Custom macros that drop in full notes with one click
• Dictation tools for fast, hands-free note-taking
• Mobile access so you can document in real time
• Built-in structure to help you meet audit and payer requirements

Tired of spending more time on notes than on care? Book a demo to see how ChiroSpring keeps you efficient, accurate, and audit-ready.
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Chiropractic Documentation FAQs

Are SOAP notes required for chiropractors?
Yes. Most states require detailed visit records to stay compliant with legal and insurance standards.

How long do I need to keep SOAP notes?
It depends on your state, but 7 years after the last visit is a common guideline.

What mistakes should I avoid in SOAP notes?
Avoid vague wording, missing exam details, or unclear plans. Notes should show what you found, what you did, and why.

Does ChiroSpring support SOAP note documentation?

Yes! With built-in automation, 50+ customizable templates, and macros, ChiroSpring makes it easy to complete SOAP notes quickly and confidently.

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References

Lew, V., Ghassemzadeh, S., & Podder, V. (2023, August 28). SOAP notes. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482263/

Simple Chiropractic Notes: Producing Audit-Ready SOAP Notes with Ease. (2025, February 11). ChiroSpring. https://www.chirospring.com/articles/simple-chiropractic-notes-producing-audit-ready-soap-notes-with-ease

Weidner, K. K. (2021, March 8). New code documentation changes and tips to avoid audits. Chiropractic Economics. https://www.chiroeco.com/code-documentation/