When I first entered chiropractic school, I knew a surprisingly small amount of what a typical day in the life of a chiropractic physician actually was. While of course I envisioned a day full of adjusting patients and treating your stereotypical back pain, I was far less knowledgeable about our true scope of practice. Even more shocking, I knew nothing about the type of paperwork and documentation that goes into patient care. Like any other health care profession, proper documentation is critical, not just for patient care, but also for legal protection, data security and billing purposes. There’s far more paperwork to complete, scan or upload into your electronic health record (EHR) system than I ever imagined. This includes everything from patient intake forms and past medical histories to pain scales and outcome assessment tools. Above all, the most important documentation we deal with is something known as a SOAP note.
SOAP notes, an acronym for subjective, objective, assessment and plan, are our method of documenting everything we do or plan to do with our patients. Learning how to complete an exemplary SOAP note can be the difference between being a great practitioner, and a great physician. Proper documentation is key to ensuring continuity of care, minimizing risk of liability or malpractice (especially in case of an audit) and receiving proper reimbursement from insurance companies. We’re taught how to write these SOAP notes in the clinical phase of our program, but it is a skill we must continue to refine throughout being in clinic and in our careers. This is precisely why I wanted to give a crash course for anyone looking to improve their own note-writing abilities.
Subjectivity…Objectivity…Assessment
The subjective portion of the note, also often interchanged with the history of present illness, or HPI for short, is all about the patient’s account of their reason for being seen. A thorough interview that includes location of chief complaint, pain rating and description of the nature of the pain and aggravating or alleviating factors are crucial to ensuring proper diagnosis and treatment. This part of your note is written after conducting a thorough patient interview.
The objective portion, also referred to as the physical exam, or PE for short, is simply a documentation of the objective findings in the visit. This includes your ranges of motion, neurological examinations, palpation and restrictions as well as orthopedic examinations. Once again, proper evaluation allows for the highest level of care and prepares us to provide the best treatment we can to each individual patient.
The assessment part of the note is all about the doctor’s decision and interpretation of both the subjective and objective findings. This is where we discuss and note the patient’s diagnosis or differential diagnosis, prognosis and discuss our evaluation. The variables can be impacted based on our clinical decision making skills regarding both the presentation and external or contributing factors such as patient demographics. The plan is simply what we did in the office, and what we plan to continue to do to treat our patient.
Wrapping it Up
While every new and aspiring chiropractic student may be eager to jump straight into adjusting, it’s just as important to master proper documentation. I hope this post helps you better understand the value of SOAP notes and medical documentation—an integral part of our future as health care professionals.
Meet some of NUHS’ Doctor of Chiropractic Medicine students.
