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Chiropractic SOAP Note Template
A chiropractic SOAP note records each treatment visit: pain and function since the last visit, your findings by segment, the adjustments and therapies given, and the response. Copy the free template, see two filled examples, and check what goes in each section.
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- Two filled examples
Blank chiropractic SOAP note template
FreeCHIROPRACTIC SOAP NOTE Patient: [Name] Date of birth: [Date] Date of visit: [Date] Visit: [Visit number in the current plan of care] Chiropractor: [Name, credentials] SUBJECTIVE Chief complaint: [Region and main symptom, in the patient's words] Pain today: [Rating out of 10 now; best and worst since the last visit] Radiation: [Into an arm or leg, and how far, or none] Response to last visit: [Relief, how long it lasted, any soreness after treatment] Function: [Sitting, sleep, work, or sport tolerance compared with the last visit] New symptoms: [Numbness, weakness, bladder or bowel changes, dizziness, or none] OBJECTIVE Posture and gait: [Antalgic lean, guarding, gait changes] Palpation: [Tenderness, hypertonicity, and trigger points, by side and level] Segmental findings: [Restricted or fixated segments by level, with listing if your technique uses one] Range of motion: [Active motion by direction, in degrees or percent of normal, with pain] Orthopedic tests: [Test, side, and result] Neurological screen: [Dermatomes, myotomes, and reflexes, or not repeated and why] ASSESSMENT Diagnosis: [Working diagnosis by region] Progress: [Better, unchanged, or worse since the last visit, with the measure that shows it] Goals: [Short-term goals met, progressing, or not met] Safety: [Red flags and contraindications screened, and any change in technique] PLAN Adjustments: [Region, segments, technique, and patient position] Adjunct therapies: [Soft tissue work, modalities, or traction, with region and minutes] Response to treatment: [Change in pain or motion after treatment, and any adverse effects] Home care: [Exercises, activity, and ergonomic advice] Next visit: [Visits per week, and the date of the next re-exam] Signed: [Chiropractor name, credentials, date and time]
Use it for
- Treatment visits
- Acute back pain
- Neck pain and headaches
- Active care plans
- Multidisciplinary clinics
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Chiropractic SOAP note: acute low back pain
Chiropractic clinic, visit 3 of the initial plan
Subjective
38-year-old man with low back pain for 6 days, after lifting a heavy box at home. Pain 4/10 today, down from 7/10 at the initial exam; worst 5/10, getting out of the car. No pain below the buttock. Relief lasted about 2 days after the last visit, with mild soreness the first evening. Now sits 45 minutes at work before needing to stand, up from 15. No numbness in the groin, bladder or bowel changes, or leg weakness.
Objective
Walks without a limp; slight guarding when sitting down. Tender, hypertonic right lumbar paraspinals at L4 and L5, and right quadratus lumborum. Motion palpation: restricted L4-L5 and right sacroiliac joint. Lumbar flexion about 70% of normal, with pain at end range; extension 80%, painful on return to upright. Kemp’s test positive on the right for local pain, without leg symptoms. Straight-leg raise negative on both sides. Neurological screen normal at the initial exam; not repeated, as there are no new symptoms.
Assessment
Acute mechanical low back pain with L4-L5 and right sacroiliac joint dysfunction. Improving: pain 7/10 to 4/10, sitting tolerance 15 to 45 minutes. Short-term goal of sitting 30 minutes met; goal of pain at 3/10 or less progressing. No red flags; no contraindications to manipulation.
Plan
Side-posture diversified adjustment, L4-L5 and right sacroiliac joint. Soft tissue work to the right lumbar paraspinals and quadratus lumborum, 8 minutes. Flexion about 85% after treatment; pain 3/10 on leaving; no adverse effects. Home care: walk 20 minutes a day, cat-camel 10 times twice a day, and lift by bending at the hips and knees. Next: twice a week for 2 more weeks, with a re-exam and Oswestry at visit 6. Seek urgent care for numbness in the groin, bladder or bowel changes, or leg weakness.
Chiropractic SOAP note: neck pain with headaches
Chiropractic clinic, visit 5 of the initial plan
Subjective
41-year-old woman with right-sided neck pain and headaches that start at the base of the skull, worse after long days at a laptop. Neck pain 4/10 today, down from 6/10 at the initial exam. Headaches 3 times this week, down from 5, each lasting 2 to 4 hours and eased by ibuprofen. No dizziness, double vision, trouble speaking or swallowing, numbness, or sudden severe headache.
Objective
Forward head posture. Tender right suboccipitals; trigger point in the right upper trapezius that reproduces her usual headache. Restricted C1-C2 rotation to the right, C5-C6 on the right, and T3-T5. Cervical rotation 60° right and 75° left; extension painful at end range. Flexion-rotation test positive on the right: about 25° to the right, 40° to the left. Spurling’s test negative on both sides. Upper limb strength, sensation, and reflexes normal.
Assessment
Cervicogenic headache and mechanical neck pain, with C1-C2, C5-C6, and upper thoracic segmental dysfunction. Improving: headaches 5 to 3 a week, neck pain 6/10 to 4/10. Goal of fewer than 2 headaches a week progressing. Screened for cervical artery warning signs and other red flags; none present.
Plan
Prone diversified adjustment, T3-T5. Supine diversified adjustment, C5-C6 right. Mobilization of C1-C2 into right rotation. Ischemic compression to the right upper trapezius trigger point, and soft tissue work to the suboccipitals, 8 minutes. Right rotation 70° after treatment; no adverse effects. Home care: chin tucks, 10 holds of 10 seconds twice a day; laptop raised to eye level, with a separate keyboard. Next: weekly for 3 weeks, with a re-exam and Neck Disability Index at visit 8. Seek emergency care for a sudden severe headache, new dizziness, double vision, or trouble speaking or swallowing.
What goes in each part.
Subjective
How the patient has done since the last visit, in numbers you can compare from visit to visit.
- Pain rating now, and best and worst since the last visit
- Whether symptoms spread into an arm or leg
- How long relief lasted, and any soreness after treatment
- A functional measure, such as sitting or sleep tolerance
- New symptoms that could be red flags
Avoid: “Feeling better” with no number. Without a rating or a function, the next visit has nothing to compare with.
Objective
Your findings today, by region and segment, so each adjustment has a documented reason.
- Tenderness and muscle tone, by side and level
- Restricted segments, with the listing if your technique uses one
- Range of motion by direction, with pain
- Orthopedic tests with side and result
- A neurological screen when symptoms call for it
Avoid: Listing the segments you adjusted without the findings that justify them.
Assessment
The diagnosis by region, whether the patient is improving, and whether care is still safe and appropriate.
- Working diagnosis by region
- Change since the last visit, with the measure
- Progress toward short-term goals
- Red flags and contraindications screened
Avoid: “Patient responding well” without the numbers that show it.
Plan
What you did today, how the patient responded, and what happens next.
- Adjustments by region, segment, technique, and position
- Adjunct therapies with region and minutes
- Response to treatment and any adverse effects
- Home exercises and activity advice
- Visit frequency and the next re-exam date
Avoid: A plan with only passive care. Note the active care that moves the patient toward discharge.
Common mistakes, and how to avoid them.
The same note every visit
Cloned notes such as “Patient improving, adjusted full spine” can’t show progress or support continued care. Update the pain rating, findings, segments, and response each time.
Adjustments without findings
Every region you adjust needs findings in Objective that support it. Many chiropractors document each segment with PART: pain or tenderness, asymmetry, range of motion change, and tissue tone.
Skipping the safety check
Ask about new neurological symptoms, cauda equina signs, and cervical artery warning signs at each visit, and note when you changed technique, for example for osteoporosis.
Pain scores as the only measure
Pair pain ratings with range of motion, a functional target, and a named outcome measure such as the Oswestry or Neck Disability Index, repeated at each re-exam.
No path to discharge
Write the visit frequency, the next re-exam, and the goals you are working toward, so the plan of care has an end point.
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Frequently asked questions.
What should a chiropractic SOAP note include?
The pain rating and function since the last visit, today’s findings by segment, the diagnosis and progress, the adjustments and therapies given with the response, home care, and when the patient returns.
How do I document subluxation or segmental dysfunction?
Name the level and side, and the findings that support it: tenderness, asymmetry, restricted motion, and tissue tone change. Add the listing if your technique uses one.
Where do adjustments go in a chiropractic SOAP note?
In Plan, as today’s treatment, with region, segments, technique, and patient position. Some clinics add a separate Treatment section; either works if your notes are consistent.
How often should I repeat outcome measures?
At the initial exam and at each re-exam, commonly every few weeks or after a set number of visits. Use the same measure each time, such as the Oswestry for low back pain or the Neck Disability Index for neck pain.
Is this chiropractic SOAP note template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
More chiropractic templates, and guides.
SOAP note template
The four-part note for most visits, with acute, musculoskeletal, and telehealth examples.
Chiropractic initial exam template
New-patient exam with red flag screen, orthopedic and neuro tests, consent, and a plan with goals.
Chiropractic re-exam note template
Formal reassessment against the initial exam, with outcome scores and a continue, taper, or refer decision.
AI scribe for chiropractors
SOAP drafts from the visit conversation, with more chiropractic note formats.
Vero for chiropractic practices
Visit preparation, patient documents, and follow-up in one place.
Common chiropractic diagnosis codes
The codes chiropractors use most, in one list.
How to write a SOAP note
The general guide, with a checklist and the most common mistakes.
Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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