Chiropractic SOAP Notes: Complete DC Documentation Guide
Master chiropractic documentation with comprehensive SOAP note examples, Medicare compliance requirements, subluxation documentation standards, and proper billing practices. Includes templates for initial exams, progress notes, and personal injury cases.
Why Chiropractic Documentation Matters
Chiropractic documentation serves multiple critical purposes beyond regulatory compliance. Proper SOAP notes are essential for patient safety, insurance reimbursement, legal protection, and demonstrating the medical necessity of your care. Studies show chiropractors spend 30-40% of their time on documentation, making efficient and accurate charting essential for practice sustainability.
Legal Protection
Detailed notes defend against malpractice claims and demonstrate standard of care
Insurance Reimbursement
Medicare and private payers require specific documentation for claim approval
Medical Necessity
Proves subluxation exists and treatment is medically necessary, not maintenance
Continuity of Care
Enables tracking progress, adjusting treatment plans, and communication with other providers
Compliance & Audits
Meets state board requirements and protects against insurance audits
Professional Standards
Demonstrates expertise and adherence to evidence-based practice
Critical Documentation Principle
"If it is not documented, it was not done." This legal standard applies equally to chiropractic care. Your documentation is the only evidence that examination findings exist, adjustments were performed, and informed consent was obtained. Poor documentation is the leading cause of denied insurance claims and lost malpractice cases.
The Chiropractic SOAP Format
The SOAP format is the standard for chiropractic documentation. Each section has specific requirements for chiropractic practice and insurance billing.
S - Subjective
Patient-reported information and symptoms
The subjective section captures the patient's chief complaint, pain characteristics, functional limitations, and history. Use direct quotes for the chief complaint.
Chief Complaint
Patient's primary concern in their own words (quoted)
History of Present Illness
OPQRST format: Onset, Provocation/Palliation, Quality, Region/Radiation, Severity (0-10 scale), Temporal pattern
Pain Characteristics
Location, quality (sharp, dull, aching, burning), intensity (VAS 0-10), frequency, duration
Functional Impact
How symptoms affect daily activities, work, sleep, exercise
Previous Treatment
What has helped or not helped, medications tried, other providers seen
Review of Systems
Red flags: fever, weight loss, numbness/tingling, bowel/bladder changes, progressive weakness
O - Objective
Measurable clinical findings and examination results
Objective findings are the foundation of subluxation documentation. Include quantifiable measurements, test results, and palpation findings.
Vital Signs
Blood pressure, heart rate, weight (document at initial visit and periodically)
Postural Analysis
Observe alignment in all three planes, head carriage, shoulder level, pelvic tilt, spinal curves
Gait Analysis
Normal vs. antalgic, limping, coordination
Range of Motion
Measure and document in degrees for affected regions, note pain reproduction
Orthopedic Tests
Specific tests for region (SLR, Kemp's, Spurling's, etc.), document positive/negative findings
Neurological Exam
Deep tendon reflexes, motor strength (0-5 scale), sensory testing, pathological reflexes
Palpation
Static and motion palpation, document tenderness, spasm, temperature, texture, segmental dysfunction
Muscle Testing
Manual muscle testing for weakness or inhibition
A - Assessment
Clinical diagnosis and impression
Your assessment synthesizes subjective and objective findings into diagnoses with proper ICD-10 codes. Must include subluxation complex for chiropractic billing.
Primary Diagnosis
Working diagnosis with ICD-10 code (e.g., M54.5 Low back pain)
Subluxation Complex
Specific segment(s) with ICD-10 M99 codes (M99.03 for lumbar, M99.01 for cervical, etc.)
Associated Findings
Secondary conditions: muscle spasm, joint dysfunction, postural abnormalities
Clinical Impression
Your synthesis of findings and clinical reasoning
Severity/Complexity
Acute vs. chronic, mild/moderate/severe, simple vs. complex presentation
Prognosis
Expected outcome and timeframe based on evidence and clinical experience
P - Plan
Treatment provided and ongoing care strategy
Document specific treatment provided (which segments adjusted, what techniques used), frequency of care, home instructions, and measurable goals.
Treatment Provided
Specific adjustments (segments, technique used: Diversified, Thompson, Activator, etc.)
Adjunctive Therapies
Soft tissue work, physiotherapy modalities (ultrasound, e-stim, ice/heat)
Therapeutic Exercise
Specific exercises prescribed with sets/reps
Treatment Frequency
Number of visits per week and duration of care plan (e.g., 3x/week for 4 weeks)
Home Care Instructions
Ice/heat, activity modifications, ergonomic advice, exercises
Patient Goals
SMART goals: pain reduction, ROM improvement, functional milestones
Re-evaluation Date
When you'll reassess progress and modify treatment plan
Complete Chiropractic SOAP Note Examples
Real-world examples demonstrating proper documentation for different case types and visit scenarios.
Initial Examination
New patient with acute low back pain
Date: 01/15/2025 Patient: John Smith DOB: 03/14/1978 SUBJECTIVE Chief Complaint: "Sharp pain in my lower back that shoots down my right leg." History of Present Illness: 47 y/o male presents with acute onset low back pain starting 3 days ago while lifting boxes at work. Pain rated 8/10, sharp and stabbing quality, radiating into right posterior thigh to knee level. Pain worse with forward flexion, prolonged sitting, and sneezing. Relieved slightly by lying down. Denies numbness/tingling in extremities. No bowel/bladder changes. No prior history of low back pain. Past Medical/Surgical History: Hypertension (controlled with medication). No surgeries. Current Medications: Lisinopril 10mg daily Social History: Office manager, sits 6-8 hours/day. Non-smoker. Occasional alcohol use. Review of Systems: Denies fever, recent weight loss, saddle anesthesia, progressive weakness. OBJECTIVE Vital Signs: BP 128/82, HR 76, Wt 195 lbs, Ht 5'10" Postural Analysis: Right lateral pelvic tilt. Forward head posture. Reduced lumbar lordosis. Gait: Antalgic gait favoring right leg. Range of Motion (Lumbar Spine): - Flexion: 40° (restricted, pain at 7/10) - Extension: 15° (pain at 5/10) - Right Lateral Flexion: 20° (pain at 4/10) - Left Lateral Flexion: 25° (pain at 6/10) - Right Rotation: 30° (pain at 5/10) - Left Rotation: 35° (limited) Orthopedic Tests: - Straight Leg Raise (SLR): Positive right at 35° (reproduces radiating pain) - Braggard's: Positive right - Kemp's: Positive right - Valsalva: Positive (increases pain) - Patrick's (FABER): Negative bilateral Neurological Examination: - DTRs: Patellar 2+/2+ bilaterally, Achilles 2+/2+ bilaterally - Motor: 5/5 strength all major muscle groups bilateral lower extremities - Sensory: Intact to light touch L1-S1 dermatomes bilaterally - Babinski: Negative bilateral Palpation Findings: - Marked tenderness and spasm bilateral lumbar paraspinals L4-S1 - Restricted motion palpation L5 with right rotation fixation - Sacroiliac joint restriction right side - Trigger points bilateral quadratus lumborum Static Palpation: Posterior-inferior right ilium. Right transverse process L5 prominent. Motion Palpation: - L5: Fixation in right rotation, decreased flexion/extension - Sacrum: Right posterior rotation - L4: Hypomobile in extension ASSESSMENT 1. Lumbar radiculopathy, right L5 nerve root involvement (M54.16) 2. Subluxation complex L5 (M99.03) 3. Sacroiliac joint dysfunction, right (M53.2X8) 4. Lumbar segmental somatic dysfunction (M99.03) 5. Lumbar myofascitis/spasm (M79.1) Clinical Impression: Acute lumbar disc syndrome with right L5 radiculopathy. Subluxation complex at L5-S1 with associated paravertebral muscle spasm and SI joint dysfunction. Positive tension signs suggest disc involvement. Neurologically intact. No red flags present. Good candidate for conservative chiropractic care. PLAN Diagnostic: Lumbar spine X-rays (AP, Lateral, obliques) ordered to rule out pathology and assess for subluxation patterns. Treatment Plan: - Spinal manipulation therapy (SMT) to L5-S1, sacroiliac joint - Soft tissue therapy to lumbar paraspinals and gluteal muscles - Therapeutic exercises: Core stabilization, McKenzie extension protocol - Ice therapy for acute inflammation - Patient education on proper lifting mechanics and posture Frequency: 3x/week for 4 weeks, then re-evaluate (12 visits) Home Care Instructions: - Ice lumbar spine 15-20 minutes every 2-3 hours for first 48-72 hours - Avoid prolonged sitting, use lumbar support when sitting - Avoid forward flexion and heavy lifting - Perform prescribed exercises 2x daily Patient Goals: Reduce pain to 2/10 within 4 weeks, return to normal work activities without restriction, improve lumbar ROM to within functional limits. Follow-up: Re-evaluation in 2 weeks or sooner if symptoms worsen. Discussed red flags warranting immediate medical evaluation (progressive weakness, bowel/bladder changes, saddle anesthesia). Informed Consent: Risks, benefits, and alternatives to chiropractic care discussed. Patient verbalized understanding and consented to treatment.
Routine Adjustment Visit
Established patient, maintenance care
Date: 01/15/2025 Patient: Sarah Johnson Visit #: 8 of 12 SUBJECTIVE Chief Complaint: "My neck has been tight this week." Since Last Visit: Patient reports overall improvement in cervical pain from 6/10 to 3/10. Increased stress at work this week led to increased neck tension and headaches. Headache frequency decreased from 5x/week to 2x/week. Sleeping better. Has been compliant with home exercises. Current Pain: 3/10 neck pain, mild tension-type headache this morning (2/10). No radiating symptoms. Activities: Returned to yoga class 2x this week without exacerbation. Using ergonomic workstation setup as recommended. OBJECTIVE Vital Signs: BP 118/76 Posture: Improved forward head posture compared to initial visit. Mild right shoulder elevation. Cervical ROM: - Flexion: 55° (improved, minimal discomfort) - Extension: 65° (full, pain-free) - Right Rotation: 75° (full) - Left Rotation: 70° (slight restriction) - Right Lateral Flexion: 40° (full) - Left Lateral Flexion: 38° (full) Palpation: - Mild tenderness upper trapezius bilaterally (improved) - Slight restriction C5-C6 with left rotation - Suboccipital tension decreased from previous visit - No spasm noted Motion Palpation: - C5: Mild restriction left rotation (improved from moderate) - C6: Mobile, unrestricted - Upper thoracic: T1-T2 slight restriction Muscle Testing: Cervical musculature 5/5, symmetric bilateral. ASSESSMENT 1. Cervical subluxation complex C5 (M99.01) - improving 2. Cervicogenic headache (M53.0) - responding well to treatment 3. Cervical myofascial pain syndrome (M79.1) - improved Clinical Progress: Patient demonstrating excellent response to care. Pain reduced by 50% since initial visit. ROM improved. Headache frequency decreased significantly. Continues to have mild restriction C5-C6 requiring continued treatment. PLAN Treatment Provided Today: - Diversified technique adjustment C5 (seated) - Activator instrument adjustment T1-T2 - Soft tissue therapy: Trigger point release bilateral upper trapezius and levator scapulae - Therapeutic exercise instruction: Chin tucks, cervical retractions Recommendations: - Continue current treatment frequency (2x/week) - Maintain home exercise program - Stress management techniques for work-related tension - Ergonomic break every 30 minutes at work Next Visit: Scheduled in 3 days Re-evaluation: Scheduled for visit 12 to assess progress toward functional goals and determine ongoing care needs. Patient Response to Today's Treatment: Tolerated adjustment well. Reports immediate reduction in muscle tension. No adverse reactions.
Personal Injury Case
Motor vehicle accident patient
Date: 01/15/2025 Patient: Michael Rodriguez Accident Date: 01/10/2025 SUBJECTIVE Chief Complaint: "Neck and upper back pain since my car accident 5 days ago." Mechanism of Injury: Patient was driver of vehicle that was rear-ended while stopped at red light on 01/10/2025. Estimates impact speed 25-30 mph. Was wearing seatbelt. No airbag deployment. No loss of consciousness. No immediate pain, but neck stiffness began 3-4 hours post-accident and progressively worsened over next 24-48 hours. Current Symptoms: - Neck pain 7/10, constant aching with sharp pain on movement - Upper back pain 6/10, bilateral between shoulder blades - Headaches (occipital region) 5/10, daily since accident - Right shoulder pain 4/10 - Difficulty sleeping due to pain - Decreased concentration at work Pain Pattern: Worse in morning, improves slightly with movement then worsens with prolonged activities. Aggravated by turning head to check blind spot while driving. Medical Treatment: Evaluated at ER day of accident. X-rays of cervical spine negative for fracture. Given muscle relaxants (cyclobenzaprine) and NSAIDs (ibuprofen). Medications provide minimal relief. Work Status: Missing work since accident. Occupation: Construction supervisor. OBJECTIVE Vital Signs: BP 134/88, HR 82 Posture: Cervical spine held in protected position. Loss of normal cervical lordosis. Forward head posture. Gait: Guarded, moving neck and trunk as single unit. Cervical ROM (SFMA): - Flexion: 25° (severely restricted, pain 8/10) - Extension: 20° (restricted, pain 7/10) - Right Rotation: 35° (restricted, pain 7/10) - Left Rotation: 30° (restricted, pain 8/10) - Right Lateral Flexion: 20° (restricted, pain 6/10) - Left Lateral Flexion: 18° (restricted, pain 6/10) Orthopedic Tests: - Cervical Compression: Positive bilateral (reproduces neck pain) - Cervical Distraction: Negative (no relief) - Shoulder Depression: Positive bilateral - Maximum Cervical Compression: Positive - Spurling's: Negative bilateral Neurological: - DTRs: Biceps 2+/2+, Triceps 2+/2+, Brachioradialis 2+/2+ - Motor: 5/5 all major muscle groups bilateral upper extremities - Sensory: Intact C5-T1 dermatomes bilaterally - No signs of myelopathy Palpation: - Severe spasm bilateral cervical paraspinals C2-C7 - Marked tenderness bilateral upper trapezius, levator scapulae - Suboccipital muscle hypertonicity bilateral - Tenderness bilateral rhomboids - Restricted motion all cervical segments, most significant C4-C5, C5-C6 Motion Palpation: - C4: Fixation in extension and bilateral rotation - C5: Fixation in flexion and right rotation - C6: Bilateral restriction - T1-T4: Multiple restrictions ASSESSMENT 1. Cervical strain/sprain (whiplash), acute (S13.4XXA) 2. Cervical subluxation complex C4-C6 (M99.01) 3. Thoracic subluxation complex T1-T4 (M99.02) 4. Post-traumatic cervicogenic headache (G44.841) 5. Cervical myofascial pain syndrome, acute (M79.1) 6. Cervical segmental somatic dysfunction (M99.01) Diagnosis: Cervical acceleration-deceleration injury (whiplash-associated disorder Grade II) with significant muscle spasm, restricted cervical range of motion, and multiple subluxations. Post-traumatic headaches consistent with cervicogenic origin. Prognosis: Guarded to fair. Soft tissue injuries from MVA typically require 8-12 weeks of intensive treatment. Patient is motivated and previously healthy, which are positive prognostic factors. PLAN Diagnostic Imaging: Cervical spine X-rays (AP, Lateral, APOM, Flexion/Extension stress views) to assess alignment, rule out instability, and document subluxation patterns. MRI consideration if no improvement within 4-6 weeks or if radicular symptoms develop. Treatment Plan - Phase 1 (Acute Phase, Weeks 1-2): - Gentle spinal manipulation therapy using drop table/Activator to cervical and thoracic spine - Soft tissue therapy: Muscle energy technique, light myofascial release - Cryotherapy to reduce acute inflammation - Electrical muscle stimulation for muscle spasm - Frequency: 3-4x/week Treatment Plan - Phase 2 (Recovery Phase, Weeks 3-6): - Progress to manual adjustments (Diversified technique) - Active rehabilitation exercises: Cervical stabilization, proprioception training - Postural correction exercises - Frequency: 3x/week Treatment Plan - Phase 3 (Strengthening Phase, Weeks 7-12): - Continue adjustments 2x/week - Progressive resistance exercises - Functional movement training - Return-to-work conditioning - Frequency: 2x/week, then 1x/week Total Estimated Visits: 28-36 visits over 12 weeks Home Care: - Ice cervical spine 15-20 minutes every 2-3 hours for first week - Gentle ROM exercises as tolerated after first week - Avoid overhead activities and heavy lifting - Sleep positioning: Cervical pillow, avoid stomach sleeping Work Restrictions: Recommend light duty for 2 weeks: No lifting >10 lbs, no overhead work, frequent position changes, avoid prolonged static postures. Referrals: Will co-manage with patient's primary care physician. Orthopedic or neurosurgical referral if symptoms don't improve or worsen. Re-evaluation: In 2 weeks to assess progress and modify treatment plan as needed. Medical-Legal Documentation: Patient involved in MVA 01/10/2025. Claim #MVA2025-4782. Attorney: Johnson & Associates. All documentation will be provided for legal case as requested. Patient Education: Discussed typical recovery timeline for whiplash injuries, importance of compliance with treatment plan, and red flags warranting immediate medical evaluation (progressive weakness, loss of bowel/bladder control, severe worsening of pain). Informed Consent: Discussed treatment plan, expected outcomes, and potential risks. Patient verbalized understanding and consented to chiropractic care.
Medicare Documentation Requirements
Medicare has specific requirements for chiropractic services. Understanding these is critical to avoid claim denials and audit issues.
Medical Necessity
Document subluxation complex with both a misalignment AND nerve involvement affecting body function
Example: Must show how the subluxation is causing the patient's symptoms, not just that misalignment exists
Subluxation Documentation
Must include at least 2 of 4 criteria: asymmetry/misalignment, ROM changes, tissue texture changes, or pain/tenderness
Example: L5 subluxation: (1) Posterior-right rotation on palpation, (2) Restricted flexion ROM, (3) Paraspinal spasm
Treatment Plan
Specific number of visits over specific timeframe with expected outcomes
Example: 3x/week for 4 weeks (12 visits) to reduce pain by 50% and improve ROM to functional levels
Maintenance Care
Medicare does NOT cover maintenance/wellness care. Only active treatment for subluxation.
Example: Document ongoing subluxation with objective findings at each visit, not just "maintenance adjustment"
Re-evaluation
Regular reassessment every 2-4 weeks showing either improvement or justification for continued care
Example: Re-exam at visit 12: Pain improved from 8/10 to 3/10, ROM increased by 40%, but restriction remains
Provider Signature
Must be signed and dated by treating chiropractor on same day as service
Example: Each SOAP note must have handwritten or electronic signature with credentials (DC)
Medicare Does NOT Cover:
- Maintenance or wellness care (preventive adjustments without active subluxation)
- X-rays, laboratory tests, or other diagnostic services
- Physical therapy modalities (ultrasound, electrical stimulation, massage)
- Treatment of subluxations outside the spinal column (extremities)
Documenting Adjustments & Techniques
Proper documentation of adjustments includes the specific technique, segment adjusted, listing (if applicable), patient position, and response to treatment.
Diversified Technique
Most common adjustment method using high-velocity, low-amplitude (HVLA) manual thrust
Documentation Example:
Diversified adjustment C5 (P-L listing), audible release obtained
Activator Methods
Instrument-assisted adjustment using spring-loaded device for controlled force
Documentation Example:
Activator IV adjustment L5 (PI listing), setting 2, patient prone
Thompson Drop Table
Uses segmented table with drop pieces for reduced force adjustments
Documentation Example:
Thompson drop technique S1 (AS-left), drop piece activated, patient prone
Gonstead Technique
Specific adjusting emphasizing intervertebral disc and biomechanics
Documentation Example:
Gonstead cervical chair adjustment C6 (PRS), double transverse contact
Cox Flexion-Distraction
Gentle stretching technique for disc injuries using specialized table
Documentation Example:
Cox flexion-distraction L4-L5, 15 flexion cycles, caudal distraction
SOT (Sacro-Occipital Technique)
Uses pelvic blocks and positional releases
Documentation Example:
SOT category II blocking, blocks placed bilateral PSIS, 5 minutes
Key Elements of Adjustment Documentation
- Specific segment(s) adjusted (C5, L5, sacrum, etc.)
- Technique used (Diversified, Activator, Thompson, etc.)
- Listing system if applicable (PRS, PI, AS-L, etc.)
- Patient position (prone, supine, side-lying, seated)
- Contact point (spinous, transverse, mammillary process)
- Direction of thrust or force application
- Whether cavitation/audible release occurred
- Patient tolerance and immediate response
- Any adverse reactions or complications
- Post-adjustment findings (pain level, ROM, etc.)
Common Documentation Mistakes to Avoid
These frequent errors lead to denied insurance claims, failed audits, and potential legal liability.
Documenting only "adjustment performed" without specifics
Avoid:
Patient adjusted today. Tolerated well.
Better:
Diversified adjustment L5 (posterior-right rotation listing), audible release obtained. Patient tolerated well, no adverse reactions. Post-adjustment pain decreased from 7/10 to 4/10.
Why it matters: Insurance requires specific documentation of segments adjusted, technique used, and patient response for billing.
Failing to document subluxation for Medicare billing
Avoid:
Low back pain. Adjusted lumbar spine.
Better:
Subluxation complex L5 (M99.03) with: (1) Posterior-right rotation palpation, (2) Restricted flexion ROM 40° (normal 60°), (3) Bilateral paraspinal muscle spasm, (4) Tenderness over L5 transverse process.
Why it matters: Medicare requires documentation of subluxation with at least 2 of 4 criteria. Without this, claims will be denied.
Copy-paste notes without updating findings
Avoid:
Copying exact same palpation findings and ROM measurements visit after visit.
Better:
Document actual findings at each visit. If improved: "Paraspinal spasm improved from severe to moderate, ROM increased from 40° to 50°." If unchanged, explain why: "No change in ROM due to patient non-compliance with home exercises."
Why it matters: Identical documentation suggests fraud. Progress notes must show either improvement or clinical rationale for continued care.
Not documenting red flags when present
Avoid:
Patient mentions bladder incontinence started yesterday but chiropractor doesn't address it in notes.
Better:
Patient reports new onset urinary incontinence starting yesterday. Immediate medical referral made to Dr. Smith. Patient advised to proceed to ER if symptoms worsen. Will not perform manipulation until cleared by MD.
Why it matters: Failure to recognize and document red flags can be malpractice. Cauda equina syndrome, fractures, infections require immediate medical attention.
Using technique names without describing what was done
Avoid:
Thompson drop performed.
Better:
Thompson drop technique utilized for sacral adjustment (AS-left listing). Patient prone position, drop piece #3 activated, light thrust applied to left sacral base. Pelvic drop observed, patient tolerated well.
Why it matters: Insurance auditors may not be familiar with technique names. Describe the actual procedure performed.
Inadequate informed consent documentation
Avoid:
Patient consents to treatment.
Better:
Discussed risks of adjustment including soreness, rare risk of disc herniation, stroke with cervical manipulation (estimated 1 in 1-2 million). Discussed benefits and alternatives (PT, medication, surgery). Patient verbalized understanding, all questions answered, written consent obtained.
Why it matters: Proper informed consent is legal protection. Must document what was discussed, not just that consent was obtained.
No documentation of patient education or home care
Avoid:
Adjusted patient and scheduled next visit.
Better:
Educated patient on proper lifting mechanics (bend knees, not back), ergonomic workstation setup, and core stabilization exercises. Prescribed: 10 pelvic tilts, 10 cat-cow stretches, 2x daily. Written instructions provided. Patient demonstrated understanding.
Why it matters: Patient education is billable and shows comprehensive care. Also reduces re-injury and improves outcomes.
Billing for time-based services without documenting time
Avoid:
Manual therapy performed.
Better:
Manual therapy (CPT 97140): Myofascial release bilateral lumbar paraspinals and quadratus lumborum, 18 minutes of direct hands-on therapy. Patient reports decreased muscle tension and improved ROM following treatment.
Why it matters: Time-based CPT codes require documentation of actual time spent. Billing without time documentation is fraud.
Listing Systems & Chiropractic Terminology
Different chiropractic techniques use different listing systems to describe vertebral misalignment. Choose one system and use it consistently.
Gonstead System
Uses letters to describe direction of vertebral body rotation and translation
Cervical Example:
PRS = Posterior Right Superior (body rotated right, tilted up on right)
Lumbar Example:
PL = Posterior Left (body rotated left)
Palmer Notation
Describes spinous process position relative to vertebral body
Cervical Example:
AS-L = Anterior Superior Left (spinous process left, body right)
Lumbar Example:
PI = Posterior Inferior (spinous process down)
Anatomical Description
Plain language description of positional findings
Cervical Example:
C5 rotated right with left lateral flexion
Lumbar Example:
L5 posterior rotation to the right
Common Chiropractic Abbreviations
Chiropractic SOAP Note Template
Use this comprehensive template as a starting point for your chiropractic documentation. Customize based on your technique system and practice requirements.
CHIROPRACTIC SOAP NOTE
=====================
Date: ____________ Patient: _______________ DOB: ___________
Visit #: ____ of ____ Claim/Case #: ___________
SUBJECTIVE
----------
Chief Complaint: " ______________________________________________ "
History of Present Illness:
[ ] New condition [ ] Exacerbation of chronic condition
Onset: ___________ Mechanism: _____________________________
Pain Location: ______________________________________________
Pain Quality: [ ] Sharp [ ] Dull [ ] Aching [ ] Burning [ ] Shooting
Pain Intensity: ___/10 (VAS) Frequency: [ ] Constant [ ] Intermittent
Aggravating Factors: ________________________________________
Relieving Factors: __________________________________________
Previous Treatment: _________________________________________
Functional Limitations:
[ ] Sleeping [ ] Work [ ] Exercise [ ] ADLs [ ] Driving
Review of Systems:
[ ] Denies red flags (bowel/bladder dysfunction, saddle anesthesia,
progressive weakness, fever, unexplained weight loss, night pain)
OBJECTIVE
---------
Vital Signs: BP ___/___ HR ___ Wt ___ lbs Ht ___
Postural Analysis:
[ ] Forward head posture [ ] Lateral pelvic tilt (R/L)
[ ] Shoulder elevation (R/L) [ ] Scoliosis [ ] Lordosis: normal/↑/↓
___________________________________________________________
Gait: [ ] Normal [ ] Antalgic [ ] Other: ___________________
Range of Motion (measure in degrees, note pain):
Cervical: Flex __° Ext __° RR __° LR __° RLF __° LLF __°
Lumbar: Flex __° Ext __° RR __° LR __° RLF __° LLF __°
Thoracic: Flex __° Ext __° RR __° LR __°
Orthopedic Tests:
[ ] SLR (R/L): Positive/Negative at __°
[ ] Kemp's (R/L): Positive/Negative
[ ] Cervical Compression: Positive/Negative
[ ] Spurling's (R/L): Positive/Negative
[ ] Valsalva: Positive/Negative
[ ] Patrick's/FABER (R/L): Positive/Negative
[ ] ____________: Positive/Negative
Neurological Examination:
Deep Tendon Reflexes:
Biceps: ___/___ Triceps: ___/___ Brachioradialis: ___/___
Patellar: ___/___ Achilles: ___/___
Motor Strength (0-5 scale): [ ] 5/5 all major groups bilateral
Specific weaknesses: _____________________________________
Sensory: [ ] Intact all dermatomes [ ] Deficits: ___________
Pathological Reflexes: Babinski ___/___
Palpation Findings:
Static Palpation:
Tenderness: ________________________________________________
Muscle spasm: ______________________________________________
Temperature changes: _______________________________________
Tissue texture: ____________________________________________
Motion Palpation:
C-spine: ___________________________________________________
T-spine: ___________________________________________________
L-spine: ___________________________________________________
Pelvis/SI: _________________________________________________
Specific Segmental Findings:
___ : Fixation in _____________ , _____________ restriction
___ : Fixation in _____________ , _____________ restriction
ASSESSMENT
----------
Primary Diagnosis:
1. ________________________________________ (ICD-10: ______)
Subluxation Complex (REQUIRED for chiropractic billing):
2. Subluxation complex _____ (ICD-10: M99.__) with:
(Document at least 2 of 4 criteria)
[ ] (1) Asymmetry/Misalignment: _________________________
[ ] (2) Range of Motion abnormality: ____________________
[ ] (3) Tissue texture changes: _________________________
[ ] (4) Tenderness/Pain: ________________________________
Associated Findings:
3. ________________________________________ (ICD-10: ______)
4. ________________________________________ (ICD-10: ______)
Clinical Impression:
_____________________________________________________________
_____________________________________________________________
Prognosis: [ ] Excellent [ ] Good [ ] Fair [ ] Guarded [ ] Poor
Expected duration of care: ___________________________________
PLAN
----
Treatment Provided Today:
Spinal Manipulative Therapy (CPT 98940/98941/98942):
Segment: _____ Technique: ____________ Listing: _____
Patient position: __________ Cavitation: Yes/No
Segment: _____ Technique: ____________ Listing: _____
Patient position: __________ Cavitation: Yes/No
Soft Tissue Therapy:
[ ] Myofascial release: ___________________________________
[ ] Trigger point therapy: ________________________________
[ ] Instrument-assisted (Graston, etc.): __________________
Physiotherapy Modalities (if applicable):
[ ] Ice/Heat: _____ minutes
[ ] Electrical stimulation: _____ minutes
[ ] Ultrasound: _____ minutes
[ ] Other: ________________________________________________
Therapeutic Exercise (CPT 97110):
Exercises prescribed: _____________________________________
Sets/Reps: ________________________________________________
Patient Response to Treatment:
Pain level post-treatment: ___/10 (from ___/10 pre-treatment)
ROM changes: _______________________________________________
Tolerance: [ ] Excellent [ ] Good [ ] Fair [ ] Poor
Adverse reactions: [ ] None [ ] __________________________
Treatment Plan:
Frequency: ___x per week for ___ weeks (total ___ visits)
Phase: [ ] Acute relief [ ] Corrective [ ] Maintenance
Goals (Measurable, Time-bound):
1. Reduce pain from ___/10 to ___/10 within ___ weeks
2. Improve ROM to functional levels (___°) within ___ weeks
3. Return to normal activities/work within ___ weeks
Home Care Instructions:
[ ] Ice/Heat protocol: ____________________________________
[ ] Ergonomic modifications: ______________________________
[ ] Activity restrictions: ________________________________
[ ] Home exercises: 2x daily, demonstrated and understood
Re-evaluation: Scheduled for ___________ or visit # ___
Referrals/Co-management:
[ ] None needed at this time
[ ] Refer to: _____________________________________________
Patient Education:
Topics covered: ___________________________________________
Written materials provided: [ ] Yes [ ] No
Patient questions answered: [ ] Yes
Informed Consent:
[ ] Risks, benefits, alternatives discussed
[ ] Patient verbalized understanding
[ ] Consent obtained: Written/Verbal
Next Appointment: ___________
_________________________ DC Date/Time: ___________
Provider SignatureSave Hours on Chiropractic Documentation
PatientNotes streamlines chiropractic SOAP notes with AI-powered templates specifically designed for DC documentation. Generate Medicare-compliant notes in minutes, not hours. Auto-populate subluxation criteria, track ROM measurements, and ensure billing compliance.
Try PatientNotes FreeFrequently Asked Questions
What must be included in chiropractic SOAP notes for Medicare?
Medicare requires documentation of subluxation with at least 2 of 4 criteria: (1) asymmetry/misalignment, (2) range of motion changes, (3) tissue texture abnormality, (4) tenderness/pain. You must also document medical necessity showing how the subluxation affects function, include a specific treatment plan with frequency and duration, and provide regular re-evaluations.
How do I document a chiropractic adjustment properly?
Document the specific segment adjusted (e.g., L5, C6), the technique used (Diversified, Activator, Thompson), the listing if applicable (e.g., PRS, PI), whether cavitation occurred, patient tolerance, and immediate response. Example: "Diversified adjustment L5 (posterior-right rotation), audible release obtained, patient tolerated well, pain decreased from 7/10 to 4/10 immediately post-adjustment."
What is a subluxation complex in chiropractic terms?
A subluxation complex is a functional biomechanical spinal lesion characterized by misalignment, aberrant movement, and/or physiological dysfunction. It includes the vertebral malposition, restricted range of motion, muscle changes (spasm, hypertonicity), soft tissue involvement, and potential neurological implications. Proper documentation requires both structural findings (misalignment) and functional impact.
How often should chiropractors document patient progress?
Document a SOAP note at every patient visit. Perform comprehensive re-evaluations every 2-4 weeks (or every 10-12 visits) to reassess range of motion, orthopedic tests, and progress toward functional goals. For Medicare patients, re-evaluations are required to justify continued care and must show either improvement or explain why additional treatment is medically necessary.
Can chiropractors bill for maintenance care?
Medicare does NOT cover maintenance or wellness care. However, some private insurance plans do. For Medicare, you must document active treatment of subluxation with ongoing objective findings. For private insurance patients receiving maintenance care, clearly document this is wellness/prevention care and obtain patient signature acknowledging potential non-coverage.
What are red flags chiropractors must document?
Document screening for red flags: bowel/bladder dysfunction (cauda equina), saddle anesthesia, progressive neurological deficits, fever with back pain (infection), unexplained weight loss (cancer), severe night pain (tumor), history of cancer, prolonged steroid use (osteoporosis), major trauma, and age over 50 with new onset pain. If red flags present, document referral and decision not to manipulate.
What is the difference between motion palpation and static palpation?
Static palpation assesses position: feeling for vertebral body rotation, lateral tilting, or translation while the patient is stationary. Motion palpation assesses quality of movement: testing segmental motion (flexion, extension, rotation, lateral bending) to identify restricted or hypermobile segments. Both should be documented - static palpation identifies malposition, motion palpation identifies dysfunction.
How detailed should treatment plans be?
Treatment plans must specify: frequency (how many visits per week), duration (how many weeks), total number of visits, specific goals with measurable outcomes (e.g., "reduce pain from 8/10 to 3/10, increase lumbar flexion from 40° to 60°"), and re-evaluation date. Example: "3 visits per week for 4 weeks (12 visits total) to reduce pain by 50% and restore functional ROM, re-evaluate at visit 12."
Focus on Adjustments, Not Documentation
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