A SOAP note template has been added to this year's book, with the elements listed for each section that should satisfy Medicare, private payers, state boards, and anyone else who wants to look at your records. Some say that Medicare patients need different notes, but we think there is a way to set a standard for your office that is easy to use for everyone.
After reading Chapter 4.3 Subsequent/Treatment Visits you will get a good idea of how that works and be directed to a resource online where you can download a sample form. P.A.R.T., which is a Medicare requirement to justify a subluxation, fits well into the objective portion of a daily SOAP note. It provides a place for a reviewer to find support for the use of a diagnosis from M99.0- Segmental and somatic dysfunction. And the M99.0- codes are ideal for justification of the performance of a CMT (98940-98942). Therefore, any patient who gets adjusted should have P.A.R.T. easily located in the record.