Chiropractic SOAP note example

A follow-up visit note for a chiropractic patient with neck pain from desk work. It documents the PART findings (pain, asymmetry, range of motion, tissue changes) at each treated level, the adjustment given, and the patient's progress.

Example SOAP note

Fictional patient: Linda P., 41, fourth visit for neck pain and headaches. Any likeness to a real person is a coincidence.

Subjective

Patient reports right-sided neck pain 4/10 (6/10 at the initial visit), worse after two or more hours at the computer and eased by heat.

Headaches down from daily to two this week. No numbness, tingling or weakness in the arms.

Neck Disability Index: 24% (38% at the initial visit).

Objective

Posture: forward head carriage.

Cervical AROM: right rotation 60° (45° at the initial visit), left rotation 70°, extension 50° with pain at end range.

Palpation: tenderness and hypertonicity of the right upper trapezius and levator scapulae.

Segmental restriction and tenderness at C5–C6 right and T4–T5.

Neurological: biceps, triceps and brachioradialis reflexes 2+ and symmetrical; dermatomes intact; upper limb strength 5/5. Spurling's test negative on both sides.

Treatment: diversified chiropractic manipulation at C5–C6 and T4–T5; instrument-assisted soft tissue work to the right upper trapezius, 8 minutes; reviewed chin tucks.

No adverse response to treatment.

Assessment

Cervicalgia (M54.2) with segmental and somatic dysfunction of the cervical region (M99.01) and thoracic region (M99.02).

Improving: pain down 2 points, right rotation up 15°, NDI down 14 points since the initial visit. Headache frequency reduced.

Goal of NDI below 20% within six weeks: progressing.

Plan

Continue twice a week for two weeks, then re-examine (NDI, cervical AROM). If progress continues, reduce to once a week.

Home care: chin tucks, 10 repetitions three times a day; right upper trapezius stretch; raise the monitor to eye level and take a break every 45 minutes.

Return sooner, and consider referral, if arm numbness, tingling or weakness appears.

Why this note works

  • Findings are recorded at each treated level, so the adjustment is linked to the segments found restricted.
  • It covers PART: pain, asymmetry or posture, range of motion and tissue tone. Medicare asks for two of the four, one of them asymmetry or range of motion, to show subluxation without an X-ray.
  • A neurological screen documents that there are no red flags for nerve root involvement.
  • Progress is measured with a validated scale (NDI) and range of motion against the initial visit.
  • The Plan sets a date to re-examine and a rule for reducing visits.

What to include in each section

Subjective

  • Pain location, quality and rating (0–10), and what aggravates or eases it
  • Change since the last visit and response to the last adjustment
  • Radiating symptoms, numbness or weakness
  • Daily activities and work affected
  • Outcome questionnaire (NDI, Oswestry) if due

Objective

  • Posture and asymmetry
  • Range of motion in degrees, with pain at end range
  • Palpation: tenderness, tissue tone, segmental restriction by level
  • Orthopedic and neurological tests
  • Technique used and segments adjusted; other therapies with minutes
  • Response to treatment

Assessment

  • Diagnosis with ICD-10-CM codes, including segmental dysfunction by region
  • Progress against the initial visit and the treatment goals
  • Whether the condition is improving, stable or has reached maximum improvement

Plan

  • Visit frequency and the date of the next re-examination
  • Home care: exercises, ergonomics, heat or ice
  • When to reduce or end care
  • Referral if red flags appear

Write yours with the free SOAP note template

The template opens with the chiropractic prompts. Fill it in and download a PDF, made on your device.

Open the template

SOAP notes in CloudMedico

CloudMedico is practice management software for small practices. Choose SOAP as your visit note format in Practice settings, and every new visit's notes open with the headings Subjective, Objective, Assessment and Plan. Practices in the United States start with SOAP.

Add the visit's diagnoses from the ICD-10-CM list, and add your own visit fields for what your profession records every time, such as a pain scale or the regions treated. Each visit stays on the client's record with their appointments and invoices, and a US practice can make a superbill from the invoice.

Try CloudMedico free for 30 days

More SOAP note examples

Questions

What is PART in chiropractic documentation?

PART stands for pain or tenderness, asymmetry or misalignment, range of motion abnormality, and tissue or tone changes. Medicare accepts a subluxation shown by physical examination when two of the four are documented, one of them asymmetry or range of motion.

Should a chiropractic SOAP note list each segment adjusted?

Yes. Name the levels treated and the technique, and make sure the findings in the Objective section support each level.

Do chiropractors need a treatment plan in the note?

Yes. Medicare expects a plan with the recommended frequency and duration of visits, specific goals and the measures used to judge them, and most other payers ask for the same.

Sources

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