For the Objective section, make sure you write down data rather than conclusions. While you do want to record patient symptoms, you also want to document any observations that support or refute what the patient is telling you.
Here, you are not assessing the information, but rather recording it, along with any measurable data.
In this section, you need to synthesize the data in the previous two sections to make an unbiased evaluation based on data.
You may or may not include a diagnosis in the initial phases, but you should provide a preliminary diagnosis and indicate any additional testing or assessment that needs to occur. Follow-ups should include an independent evaluation of the impact of treatment.
The plan section should include the treatment plan, treatments given, and an explanation for why you are following this course of action. You should indicate any immediate response to treatment, along with follow-up actions, including future visits.
It’s also important to list goals and outcomes and note changes in the plan over time if necessary.
How ChiroSpring Makes SOAP Reports More Efficient
ChiroSpring provides chiropractors the ability to write fast, audit-proof, and simple chiropractic SOAP notes. A touch interface enables you to view or pull up previous notes, and macros greatly reduce the need for text input to improve speed. You can spend more time assessing and treating patients rather than recording information.
One thing chiropractors love about ChiroSpring is that the online intake from patients automatically populates the Subjective section of the SOAP notes, including outcome assessments from patients. This saves time and reduces the need to transcribe information or force patients to repeat assessments.
You can customize the format of your SOAP notes for the way that you want to work. Built-in modules make it simple to record pre-built evaluations. You can see patient progress over time in graphs, so you can show your patients their improvements. You can also quickly create and track prescribed sets of services and generate estimates.
You’ll also have these features:
- Auto-SALT (Same as Last Time) Notes: Click a button, and copy procedures or notes from the last visit to save time.
- Charge Groups: Automatically set a diagnosis, and ChiroSpring’s software will organize every insurance charge.
- Single-Click Changes: Quickly pull a previous exam into the current note, and make changes with a single click.
- Document Uploads: This feature enables you to run a 100% paperless office. Notes or supporting documents can be uploaded in any form and attached to patient records for reference.
CHIROSPRING’s SOAP notes can standardize your records and ensure that they are fully compliant with regulations and external audits. SOAP notes are kept in a secure cloud database. ChiroSpring also automatically updates your software for patches and security updates, so you don’t have to worry about it.
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Take your practice to the next level with powerful EHR proactive management software automation designed specifically for chiropractors.
ChiroSpring is an all-in-one practice management and EHR system built specifically for chiropractors to help them regain face-time with patients, spend less time on back-office tasks, maintain a limited staff, and save operational costs.
To see how ChiroSpring can help you simplify how you manage your practice, reach out to one of our specialists today!