In the chiropractic field, precise and well-structured clinical documentation is vital for effective patient care and legal compliance. The SOAP note format—comprising Subjective, Objective, Assessment, and Plan sections—is a standard approach used to document patient interactions comprehensively. Here’s a step-by-step guide to writing and formatting chiropractor’s notes using this method.

Subjective Section

The Subjective section captures the patient’s account of their symptoms and medical history. For example, a patient may report, "Sharp lower back pain began two weeks ago after lifting a heavy object, radiating down the right leg. It worsens with sitting and bending." This section should also include past medical history, such as "A history of chronic lower back pain due to a herniated disc diagnosed two years ago," and information on current medications, like "Ibuprofen 400 mg as needed for pain."

Objective Section

The Objective section records the chiropractor’s observations and findings from the physical examination. This might include vitals such as "BP 120/80 mmHg, HR 72 bpm" and physical examination notes like "Poor posture with anterior pelvic tilt and tenderness upon palpation of the L4-L5 region." This section is crucial for documenting the results of any diagnostic tests, such as "Reviewed MRI results showing a herniated disc at L4-L5."

Assessment Section

In the Assessment section, the chiropractor provides a diagnosis and identifies areas requiring attention. For example, "Diagnosis: Lumbar disc herniation with radiculopathy" and "Diagnosis codes: M51.26 (lumbar disc displacement), M54.16 (radiculopathy, lumbar region)." This section synthesizes the subjective and objective findings into a coherent clinical impression.

Plan Section

The Plan section outlines the treatment strategy and goals. For instance, "Treatment plan includes spinal adjustments at L4-L5, soft tissue therapy, and therapeutic exercises focusing on core strengthening." It’s essential to specify the frequency of treatments, such as "Twice a week for four weeks," and set clear goals like "Short-term - pain relief; Long-term - enhanced posture."

Interventions and Evaluation Sections

Document any performed interventions, for example, "Performed spinal adjustments at L4-L5," and the patient’s response, such as "The patient reported immediate relief." In the Evaluation section, assess progress, noting, "The patient shows progress towards short-term goals with reduced pain."

Incorporating AI medical scribes like Notis can revolutionize documentation practices for chiropractors. Notis is designed to automate the documentation process efficiently, transforming patient interactions into structured SOAP notes with high accuracy.

Notis significantly reduces the time spent on patient documentation by leveraging voice-to-text technology, thus allowing chiropractors to focus more on patient care. With its integration into platforms like WhatsApp, Notis offers a familiar interface, eliminating the need to learn new tools and ensuring a seamless transition.

Moreover, Notis supports multilingual transcription and provides comprehensive documentation features, including document and image analysis. By using natural language queries, chiropractors can easily retrieve patient history and manage patient records efficiently.

Overall, Notis AI Medical Scribe not only enhances the accuracy and efficiency of clinical documentation but also alleviates the administrative burden on chiropractors, enabling them to dedicate more time to patient care and improve overall practice productivity.