Chiropractic SOAP Notes Templates: Examples & Free Downloads [2025]

Writing SOAP notes doesn't have to eat up your evenings. In this guide, we'll share proven templates for the three most common chiropractic visit types, plus tips to cut your documentation time in half.

What Makes a Good Chiropractic SOAP Note?

A compliant SOAP note needs four components:

• Subjective: Patient's reported symptoms, pain levels, and history
• Objective: Your clinical findings, examination results, and measurements
• Assessment: Your professional diagnosis and clinical reasoning
• Plan: Treatment provided and future recommendations

The key is consistency. Using the same structure every time makes documentation faster and ensures you don't miss anything important.

---

Template #1: Daily Visit / Adjustment

This is your bread-and-butter template for regular adjustment visits.

Subjective

Patient presents for scheduled adjustment. Reports [pain level 0-10] in [location]. States symptoms are [better/same/worse] since last visit. [Any new complaints or changes].

Objective

Examination:

• Spinal palpation reveals subluxation at [segments]
• Paraspinal muscle tension noted at [location]: [mild/moderate/severe]
• ROM [within normal limits / restricted in specific directions]
• [Any orthopedic tests performed and results]

Vitals (if taken):

• BP: ___/___ mmHg
• Pulse: ___ bpm

Assessment

[Diagnosis codes] - [improving/stable/worsening]

Subluxation complex at [segments] with associated [muscle tension/reduced ROM/nerve involvement]

Plan

Treatment Provided:

• Chiropractic manipulation: [segments adjusted, technique used]
• [Additional therapies: e-stim, ultrasound, ice/heat, etc.]

Home Care:

• [Exercises, stretches, or lifestyle recommendations]

Follow-up:

• Return in [X days/weeks] for continued care
• [X] visits remaining in treatment plan

---

Template #2: New Patient Intake

More comprehensive documentation for initial visits.

Subjective

Chief Complaint: Patient presents with [primary complaint] for [duration].

History of Present Illness:

• Location: [specific area]
• Quality: [sharp/dull/aching/burning]
• Severity: [0-10 pain scale]
• Onset: [sudden/gradual], [mechanism if known]
• Aggravating factors: [activities that worsen]
• Relieving factors: [what helps]
• Previous treatment: [prior care received]

Past Medical History:

• [Relevant conditions, surgeries, hospitalizations]

Family History:

• [Relevant family medical history]

Social History:

• Occupation: [job type, physical demands]
• Exercise: [activity level]
• Smoking/Alcohol: [status]

Objective

Observation:

• Posture: [findings]
• Gait: [normal/antalgic/other findings]
• General appearance: [alert, oriented, no acute distress]

Palpation:

• Subluxations identified: [segments]
• Muscle tension: [locations and severity]
• Tenderness: [locations]

Range of Motion:

• Cervical: Flexion ___ Extension ___ Lateral flexion R___ L___ Rotation R___ L___
• Lumbar: Flexion ___ Extension ___ Lateral flexion R___ L___ Rotation R___ L___

Orthopedic Tests:

• [Test name]: [positive/negative]
• [Test name]: [positive/negative]

Neurological (if indicated):

• DTRs: [findings]
• Sensation: [findings]
• Motor strength: [findings]

Assessment

Diagnoses:

• [Primary diagnosis with ICD-10]
• [Secondary diagnosis with ICD-10]

Clinical Impression:

[Summary of findings and clinical reasoning]

Plan

Treatment Today:

• Chiropractic manipulation: [segments, technique]
• [Additional therapies]
• Patient education provided regarding [topics]

Treatment Plan:

• Frequency: [X times per week]
• Duration: [X weeks]
• Total visits: [number]
• Goals: [specific, measurable outcomes]

Home Instructions:

• [Ice/heat recommendations]
• [Activity modifications]
• [Exercises provided]

Follow-up: Return [date/timeframe]

---

Template #3: Re-Examination / Progress Evaluation

For periodic reassessments during care.

Subjective

Patient presents for re-examination after [X visits/weeks] of care.

Progress Report:

• Initial complaint: [original symptoms]
• Current status: [current symptoms]
• Pain level: Initial [X/10] → Current [X/10]
• Functional improvement: [specific activities now possible]
• Patient satisfaction: [patient's perception of progress]

Objective

Comparative Findings:

| Measurement | Initial | Current | Change |

|-------------|---------|---------|--------|

| Pain level | X/10 | X/10 | [improved/same/worse] |

| [Specific ROM] | X° | X° | [+/- degrees] |

| [Orthopedic test] | Positive | Negative | Resolved |

Current Examination:

• Subluxations: [current findings vs. initial]
• Muscle tension: [current vs. initial]
• ROM: [current measurements]
• Functional tests: [results]

Assessment

Progress Summary:

Patient has shown [excellent/good/fair/poor] progress toward treatment goals.

Goals Status:

• [Goal 1]: [met/partially met/not met]
• [Goal 2]: [met/partially met/not met]

Clinical Opinion:

[Interpretation of progress and prognosis]

Plan

Recommendation:

[Continue current treatment / Modify treatment plan / Discharge to PRN care]

Modified Treatment Plan (if applicable):

• New frequency: [X times per week]
• Duration: [X more weeks]
• Revised goals: [updated objectives]

Follow-up:

• Next re-evaluation: [date/visit number]
• Continue home exercises: [yes/no, any modifications]

---

Tips to Write SOAP Notes Faster

• Use templates - Don't start from scratch each time
• Document immediately - Memory fades fast
• Use abbreviations - Standard medical abbreviations save time
• Voice-to-text - Speaking is 3x faster than typing
• Batch similar notes - Do all daily visits at once

The Fastest Way: AI-Powered Documentation

If you're spending more than 2-3 minutes per note, you're working too hard.

Modern AI tools can convert your voice recordings into formatted SOAP notes automatically. Just speak your findings naturally after each patient, and get a properly structured note in seconds.

ChiroScribe was built specifically for chiropractors—it understands your terminology and formats notes the way you need them. No more typing, no more staying late.

Start your free trial →

---

Summary

Good SOAP notes don't have to take forever. With the right templates and tools:

• Daily visits: 1-2 minutes max
• New patients: 5-7 minutes
• Re-exams: 3-5 minutes

Download these templates, customize them for your practice, and consider voice-to-text tools to cut your time even further.

Your evenings belong to you, not your documentation.