Chiropractic SOAP note templates

Patient presents for routine chiropractic adjustment. Reports [intermittent/constant] [mild/moderate/severe] [low back pain/neck pain/thoracic pain] rated [X/10] on the pain scale. Symptoms [improved/worsened/unchanged] since last visit. Pain is [sharp/dull/aching] and [radiates to/localized in] [area]. Aggravating factors include [prolonged sitting/standing/lifting]. Relieving factors include [rest/ice/stretching]. Patient [is/is not] compliant with home exercises.

Vitals: BP [X/X], Pulse [X]. Posture: [Anterior head carriage/lateral shift/elevated shoulder] noted. Palpation: Hypertonicity noted in [bilateral/left/right] [paraspinal musculature/cervical/thoracic/lumbar] at [C2-C5/T4-T8/L3-L5]. ROM: [Cervical/Lumbar] [flexion/extension/lateral flexion/rotation] [WNL/restricted] at approximately [X] degrees. Orthopedic tests: [Kemp's/Straight Leg Raise/Cervical Compression/Distraction] [positive/negative] [bilaterally/on the left/on the right]. Adjustment: [Diversified/Thompson/Gonstead/Activator] technique applied to [C1/C5/T4/L4/SI joint] [bilaterally/on the left/on the right]. [Audible release obtained/Correction noted].

[Cervical/Thoracic/Lumbar] segmental dysfunction at [levels]. [Myalgia/Myofascitis] of [region]. Patient is [responding well/showing gradual improvement/plateaued] with current treatment plan. Functional improvement noted in [ADLs/work tolerance/sleep quality].

Continue chiropractic manipulative therapy [1-2x/week] for [X] weeks. Patient instructed in [stretching/strengthening/ergonomic modifications]. [Ice/Heat] therapy recommended for [15-20] minutes [as needed/2-3x daily]. Re-evaluate in [X] visits. Return as scheduled.

Patient presents [X days/weeks] post motor vehicle collision that occurred on [date]. Patient was the [driver/passenger] of a [vehicle type] that was [rear-ended/T-boned/sideswiped] while [stopped at a light/traveling at approximately X mph]. Patient [was/was not] wearing a seatbelt. Airbags [did/did not] deploy. Patient [did/did not] lose consciousness. Patient [went to ER/was seen at urgent care/did not seek immediate treatment]. Current complaints: [Neck pain X/10, low back pain X/10, headaches X/10, radiating pain to extremities]. Symptoms are [constant/intermittent] and [worsening/unchanged] since onset. Patient reports difficulty with [sleeping/driving/working/household activities]. [Currently/Not currently] missing work due to injuries.

Croft Classification: Grade [I-V] cervical acceleration/deceleration injury. Vitals: BP [X/X], Pulse [X]. Cervical ROM (inclinometer): Flexion [X°/50°], Extension [X°/60°], Right lateral flexion [X°/45°], Left lateral flexion [X°/45°], Right rotation [X°/80°], Left rotation [X°/80°]. Lumbar ROM (inclinometer): Flexion [X°/60°], Extension [X°/25°], Right lateral flexion [X°/25°], Left lateral flexion [X°/25°]. Palpation: Marked hypertonicity and tenderness at [levels]. Trigger points noted in [muscles]. Orthopedic tests: [Tests performed and results]. Neurological: DTRs [symmetric/asymmetric]. Dermatome testing [intact/diminished] at [levels]. Adjustment: [Technique] applied to [levels]. Modalities: [EMS/ultrasound/cold laser] applied to [region] for [X] minutes.

Cervical acceleration/deceleration injury, Croft Grade [X]. Cervical segmental dysfunction [levels]. Lumbar segmental dysfunction [levels]. [Cervicogenic headaches/Radiculopathy/Disc herniation] at [level]. Consistent with mechanism of injury described. Prognosis: [Good/Fair/Guarded]. Maximum medical improvement estimated at [X months].

Treatment plan: [3x/week for 4 weeks, then 2x/week for 4 weeks, then 1x/week for 4 weeks]. Modalities as indicated. Refer for [MRI of cervical/lumbar spine / orthopedic consultation / neurological evaluation] if symptoms persist or worsen. Home instructions: [ice/rest/activity modification]. Patient educated on expected recovery timeline. Next visit: [date]. Attorney: [name/firm]. Claim #: [number].

Medicare beneficiary presents for chiropractic manipulative treatment of [subluxation/neuromusculoskeletal condition] of [spinal region]. Chief complaint: [pain/stiffness/limited mobility] in [region] rated [X/10]. Symptoms [improved/unchanged/worsened] since last visit on [date]. Functional limitations: [difficulty with ADLs — specify: dressing, bathing, walking, cooking]. Patient reports [improvement/decline] in [specific functional measure].

Subluxation identified by [static palpation/motion palpation/X-ray findings dated MM/DD/YYYY] at [specific levels: L4, L5]. Palpation: Segmental restriction and hypertonicity at [levels]. ROM: [Region] [motion] measured at [X°], representing [X%] restriction from normal. Functional outcome measure: [Oswestry Disability Index / Neck Disability Index / VAS] score: [X] ([date]). Previous score: [X] ([date]). Adjustment: CMT performed at [levels] using [technique]. AT modifier applicable — treatment is active and patient is making functional improvement.

Spinal subluxation at [levels] with associated [neuromusculoskeletal condition]. Patient demonstrates [measurable/functional] improvement as evidenced by [outcome measure change / ROM improvement / ADL improvement]. Continued chiropractic manipulative treatment is medically necessary to [restore function/reduce pain/improve mobility]. Treatment is [active/maintenance — if maintenance, document why active treatment is resuming].

Continue CMT [frequency] for [duration]. AT modifier: Treatment is active — patient is making functional progress. Re-assess functional outcome measures every [30 days/12 visits]. Treatment goals: [Reduce Oswestry from X to Y / Increase lumbar flexion to X° / Return to independent ADLs]. Patient instructed in [home exercises]. Next visit: [date].

Patient presents [X days/weeks] following a [slip and fall / work injury / sports injury / other mechanism] that occurred on [date] at [location]. Mechanism: Patient [describe specific mechanism — e.g., slipped on wet floor and fell onto right side, lifted heavy object and felt sudden low back pain]. Patient [did/did not] seek immediate medical attention at [facility]. Current symptoms: [List all complaints with severity ratings]. Functional impact: Unable to [work/perform household duties/exercise/sleep comfortably]. [Currently on modified duty / out of work since date]. Prior history of [similar complaints: yes/no — if yes, document prior episodes and resolution].

Vitals: BP [X/X], Pulse [X]. Inspection: [Bruising/swelling/antalgic posture/guarding] noted at [region]. Palpation: [Tenderness/hypertonicity/spasm] at [levels/muscles]. ROM: [Region] restricted — [measurements with inclinometer]. Orthopedic tests: [Tests and results — document each thoroughly]. Neurological: [Sensory/motor/reflex findings]. Functional assessment: [Grip strength / sit-to-stand / gait analysis] — document baseline. Adjustment: [Technique] applied to [levels]. Additional therapy: [modalities with duration].

[Diagnoses with ICD-10 codes if applicable]. Injuries are consistent with reported mechanism of [injury type] on [date]. [No/Prior] history of similar complaints. Patient is in [acute/subacute/chronic] phase of recovery. Prognosis: [Good/Fair/Guarded/Poor].

Treatment frequency: [X visits/week for X weeks]. Modalities: [list]. Refer for [imaging/specialist] if [criteria]. Functional goals: [specific, measurable]. Work status: [full duty/modified duty/off work] with restrictions: [list]. Re-evaluate in [X] visits or [X] weeks. Document all correspondence with [attorney/employer/insurance].

Re-examination performed after [X visits / X weeks] of chiropractic care initiated on [date]. Original chief complaint: [complaint]. Current status: Patient reports [X% improvement / no change / worsening] in primary symptoms. Pain level: [current X/10] vs. initial [X/10]. Functional improvements: [specific ADL improvements]. Remaining limitations: [specific limitations]. Treatment compliance: Patient has attended [X of X] scheduled visits. Home exercise compliance: [excellent/good/fair/poor].

Comparative findings: ROM [Region]: Flexion: Initial [X°] → Current [X°] (Δ +[X°]) Extension: Initial [X°] → Current [X°] (Δ +[X°]) Lateral Flexion R/L: Initial [X°/X°] → Current [X°/X°] Rotation R/L: Initial [X°/X°] → Current [X°/X°] Functional Outcome Measures: [Oswestry/NDI/VAS]: Initial [X] → Current [X] (Δ -[X] points, [X%] improvement) Palpation: [Improved/unchanged] segmental restriction at [levels]. Hypertonicity [decreased/unchanged] in [muscles]. Orthopedic re-testing: [Tests] now [negative/improved/unchanged]. Neurological: [Any changes from initial exam].

Patient has achieved [excellent/good/fair/poor] progress toward treatment goals. [X of X] goals met. Remaining goals: [list]. Clinical findings [support/do not support] continued active treatment. MMI [has/has not] been reached. [If not at MMI]: Continued improvement is expected with [X additional weeks] of care.

[Continue/modify/discontinue] current treatment plan. Revised frequency: [X visits/week for X weeks]. Updated goals: [specific, measurable, time-bound]. [Transition to maintenance/wellness care on date]. [Discharge if MMI reached — provide home program]. Next re-examination: After [X visits / X weeks]. [Referral to specialist if applicable].