Free Template
SOAP Note Template for Chiropractic
Chiropractors must maintain thorough documentation for every patient encounter. SOAP notes provide the structured format required by insurance companies, state boards, and malpractice carriers. This template covers spinal adjustments, extremity work, and adjunctive therapies.
Blank Chiropractic SOAP Note Template
Copy this template and fill in the bracketed sections with your session details.
SUBJECTIVE: Patient presents with [chief complaint]. [Onset, duration, mechanism of injury if applicable]. Pain rated [X/10]. [Location, quality, radiation pattern]. [Aggravating/relieving factors]. [Relevant medical history, prior treatment]. OBJECTIVE: Postural analysis: [findings]. Palpation: [subluxation levels, muscle guarding, tenderness]. ROM: [cervical/thoracic/lumbar measurements]. Orthopedic tests: [tests performed and results]. Neurological: [if applicable — DTRs, dermatomal sensation]. Adjustments performed: [technique used — e.g., Diversified, Gonstead, Activator] at [spinal levels]. Adjunctive therapy: [e-stim, ultrasound, traction, etc.]. ASSESSMENT: [Diagnosis/clinical impression]. [Subluxation complex findings]. [Response to treatment]. [Progress toward treatment goals]. PLAN: [Frequency of visits]. [Treatment modifications]. [Home exercises/rehabilitation]. [Re-evaluation timeline]. [Referral if needed].
Filled Example — Chiropractic
Here's what a completed SOAP note looks like for a chiropractic session.
SUBJECTIVE: Patient presents with acute onset neck pain and headaches following a rear-end motor vehicle accident 5 days ago. Pain rated 7/10 in the cervical region with referral to the right occipital area. Reports stiffness worse in the morning and after prolonged computer use. Difficulty turning head to the right. Headaches are daily, starting at the base of the skull. No numbness or tingling in the extremities. OTC ibuprofen provides minimal relief. OBJECTIVE: Postural analysis reveals anterior head carriage and right lateral cervical shift. Palpation reveals significant hypertonicity and muscle guarding in the upper trapezius bilateral, right greater than left. Tenderness and restriction noted at C3-C4, C5-C6 segments. Cervical ROM: flexion 35° (normal 50°), extension 40° (normal 60°), right rotation 50° (normal 80°), left rotation 65° (normal 80°). Cervical compression test: positive right. Shoulder depression test: positive right. DTRs 2+ bilateral upper extremities. Dermatomal sensation intact. Diversified adjustments performed at C3-C4 and C5-C6 with cavitation achieved. Interferential current therapy applied to cervical paraspinals, 15 minutes. Cervical traction performed at 10 lbs for 10 minutes. ASSESSMENT: Cervical subluxation complex at C3-C4 and C5-C6 with associated myospasm and reduced ROM, consistent with cervical acceleration-deceleration injury. Cervicogenic headache secondary to upper cervical dysfunction. Patient tolerated treatment well. Slight improvement in right rotation post-adjustment. PLAN: Treatment frequency: 3x/week for 4 weeks, then reassess. Continue Diversified adjustments with IFC and cervical traction. Prescribe cervical isometric exercises and chin tuck stretches — 3 sets of 10, twice daily. Ice 15 minutes to cervical spine as needed. Re-evaluation at visit 12. MRI referral if symptoms do not improve by 50% within 4 weeks.
Documentation Tips for Chiropractic
- Document specific spinal levels adjusted and technique used
- Include measurable ROM with degrees — not just 'limited' or 'decreased'
- Record orthopedic and neurological test results, even when negative
- Note the patient's response to the adjustment (cavitation, pain change)
- For PI cases, document mechanism of injury and relate findings to the accident
- Include specific home exercise prescriptions with sets, reps, and frequency
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