Healthcare professionals rely on a specific form of documentation for note-taking. Beyond compliance, this method of notetaking allows healthcare professionals to capture essential aspects of patient care. By using consistent note-taking, medical staff can meet Medicare guidelines.
Patient progress can be overseen with proper note-taking. Not only does the official method safeguard patients, but it protects health staff. By adhering to the Medicare guidelines, you will have a more straightforward time billing, processing information by others in the field, and securing evidence that you have followed the procedures and protocols if an audit transpires.
SOAP notes must be followed by staff noting patient information. Each component of the notes serves a different purpose that helps specify patient information. Continue reading to learn more about chiropractic soap notes and how software can help you write them.
Defining Chiropractic Soap Notes
To understand chiropractic soap notes, you need to understand what SOAP notes are. ‘SOAP’ is an acronym for the following terms:
The Subjective Section
With the subjective section, you include the initial notes that deal with patient symptoms, the severity of pain, history of patient injury and general medical care, etc. This section becomes specific to chiropractic soap notes within the realm of how it applies to chiropractic care.
For example, patient symptoms will be noted for issues highly specific to chiropractic care, such as chronic back pain. You’re not recording information about mental health or medical information that is either unrelated or unhelpful to chiropractic treatment.
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The Objective Section
The objective section regards the measurable information you can trace, such as medical imaging and lab results. For chiropractic soap notes, this means information for chiropractic care, i.e., an x-ray of a fracture. Perhaps you receive an image of a lower back injury.
The Assessment Section
Based on the data and information gathered, the assessment section deals with the medical professional confirming a diagnosis and prognosis of the patient’s condition. For chiropractic soap notes, this means a diagnosis and prognosis for a chiropractic outcome, such as a fractured hip, spinal cord injury, etc.
The Plan Section
The plan section regards the specific actions the medical professional will take to carry out treatment essential for the patient. For chiropractic soap notes, this could mean ordering lab work, treatment recommendations, specialist referrals, etc.
How Software Can Optimize Note-Taking For Chiropractors
While you could take the time to script out your SOAP notes, your software can help you take notes faster. By choosing software tailored to chiropractic soap notes, you will:
- access templates for note taking
- get forms that allow for customization to address practice-specific needs
- take your notes within the software platform
- achieve security baked into your information, ensuring that your data is always compliant with established medical guidelines
Maximize Your Notetaking With The Right Software
Chiropractors looking for an efficient way to optimize their notetaking may be interested in purchasing software that allows for such an outcome. Research chiropractic note-taking software to consider your options for maximum notetaking potential.