SOAP Note Example
Chiropractic SOAP Note Example
Below is a complete SOAP note example for a chiropractic visit treating cervical pain following a motor vehicle accident. This example demonstrates proper documentation of adjustments, objective measurements, and treatment planning.
Complete Chiropractic SOAP Note
SUBJECTIVE:
Patient presents with neck pain and right-sided headaches following a rear-end motor vehicle accident 10 days ago. Pain rated 7/10 in the cervical region with referral to the right occipital area. Reports neck stiffness is worse in the morning and after prolonged computer use. Headaches occur daily, originating at the base of the skull. Difficulty turning head to the right, especially when checking blind spot while driving. No numbness or tingling in the upper extremities. Sleep disrupted due to pain — waking 2-3 times per night. OTC ibuprofen 600mg provides minimal relief lasting approximately 2 hours.
OBJECTIVE:
Postural analysis: anterior head carriage (approximately 2 inches forward of plumb line), right lateral cervical shift. Palpation: significant hypertonicity and muscle guarding in upper trapezius bilaterally, right > left. Suboccipital muscles hypertonic bilaterally. Tenderness and segmental restriction noted at C3-C4 and C5-C6. Cervical ROM (inclinometer): flexion 35° (normal 50°), extension 40° (normal 60°), right rotation 50° (normal 80°), left rotation 65° (normal 80°), right lateral flexion 25° (normal 45°), left lateral flexion 35° (normal 45°). Cervical compression test: positive right — reproduces neck pain and headache. Shoulder depression test: positive right. Jackson's compression: positive right at C5-C6 level. DTRs: biceps 2+, triceps 2+, brachioradialis 2+ bilateral — normal. Dermatomal sensation intact C5-T1 bilateral. Grip strength: 65 lbs right, 70 lbs left (dominant right). Adjustments: Diversified technique — C3-C4 right lateral to medial, C5-C6 right lateral to medial. Cavitation achieved at both levels. Adjunctive therapy: interferential current to cervical paraspinals 15 minutes (sensory level), cervical mechanical traction 10 lbs intermittent 10 minutes.
ASSESSMENT:
Cervical subluxation complex at C3-C4 and C5-C6 with associated myospasm, reduced ROM, and cervicogenic headache secondary to cervical acceleration-deceleration (whiplash) injury. Positive orthopedic tests confirm mechanical cervical dysfunction. Neurological exam is intact — no radiculopathy. Patient tolerated diversified adjustments well. Slight improvement in right rotation noted immediately post-adjustment (approximately 55° from 50°). Prognosis is good for functional recovery with consistent treatment given intact neurological status and absence of structural damage on prior ER imaging.
PLAN:
Treatment frequency: 3x/week for 4 weeks (12 visits), then reassess ROM and symptoms. Continue Diversified adjustments to C3-C4 and C5-C6 with IFC and cervical traction. Home exercises prescribed: cervical isometric exercises (flexion, extension, lateral flexion, rotation) — 5-second holds, 10 reps, 3 sets, 2x daily. Chin tuck stretches — 10 reps, hold 5 seconds, 3x daily. Ice to cervical spine 15 minutes as needed for pain, no more than 3x daily. Patient advised to limit prolonged computer use to 30-minute intervals with breaks. Re-evaluation at visit 12 including comparative ROM measurements. If symptoms do not improve by 50% within 4 weeks, referral for cervical MRI. PI documentation to be maintained for attorney and insurance correspondence.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
For injury cases, document the mechanism of injury, timeline, and functional limitations (checking blind spot while driving). Note current treatments and their effectiveness. This creates a clear link between the accident and the symptoms for insurance and legal purposes.
Objective
Chiropractic notes must include specific ROM measurements in degrees (not just 'limited'), orthopedic and neurological test results, adjustment levels and technique used, and adjunctive therapies with parameters. This level of detail is essential for insurance reimbursement and PI cases.
Assessment
Connect the findings to a clinical diagnosis. Note the response to treatment and prognosis. For PI cases, explicitly link findings to the injury mechanism. Document that neurological status is intact (or not) to guide treatment decisions.
Plan
Include specific visit frequency, treatment modifications planned, home exercises with dosage (sets/reps/frequency), and re-evaluation criteria. For PI cases, note documentation requirements. Include clear criteria for when to escalate (MRI referral if <50% improvement).
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