Here at the ChiroCode Institute, we are often asked for an template for a perfect SOAP note. We often defer back to practice management software (see our MarketPlace for some we like) which should be developed with an ideal SOAP note in mind. And read Chapter 5.2 Record Keeping in the 2016 ChiroCode DeskBook for a more thorough explanation.
The note needs to convey medical necessity, but it also needs to accurately describe a unique encounter. It should tell the story of the patient encounter to a third party who was not there to see it for themselves. SOAP is an old standard in medical records and it stands for Subjective, Objective, Assessment, and Plan. The following example is just an example. Individual reviewers may have preferences and specific guidelines. Nonetheless, here is a note, made up by Dr. Gwilliam. It is not intended as a template. Feel free to email your thoughts or suggestions to email@example.com. Dr. Gwilliam will take those into account and make updates.
S: Mary Jane presents today for continued treatment for neck pain that began three days ago. It worsens throughout the day, but generally rates 4/10 on the verbal numeric rating scale, which is an improvement from 6/10 three days ago. It is dull, achy, and located around the C3-C5 region on the right. It has decreased her quality of sleep, but no other changes are reported.
O: Involuntary muscle contraction is palpated on the right from C3 to C7, with tenderness and restricted left rotation and lateral bending. All other sectional ROM within normal limits. Restricted intersegmental motion is noted at C3, C5, and T4.
A: M99.01 Segmental dysfunction, cervical region
M62.838 Other muscle spasm (neck)
Patient appears to be responding favorably to treatment.
P: Interferential current (97014) was administered to the affected region for 10 minutes as outlined in care plan dated 1/29/2016. Chiropractic Manipulative Treatment (98940) was performed in the cervical region at C3 and C5, as well as T4. Patient will continue with care plan as outlined. She is due to return in two days.