CHIROPRACTIC 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]