How to Write an Easy SOAP Note in 15 Seconds
Key Takeaways
- Customizable Templates: ChiroSpring offers over 50 customizable SOAP note templates, including the option to create a dynamic Super Note, ensuring efficient and standardized documentation.
- Auto SALT: Auto SALT (Same As Last Time) automates data entry by populating notes with information from previous visits, reducing repetition and errors, and enhancing patient understanding and care quality.
- SOAP Macros and Dictation: SOAP macros generate pre-defined sentences or paragraphs with a single click, while dictation support enables hands-free note-taking, further speeding up the process and ensuring accuracy.
A Simple Step-by-Step Guide to Faster Chiropractic SOAP Notes
Running a practice is already demanding enough without the extra work chiropractic SOAP notes create. Between juggling patient consultations, adjusting patients, and navigating endless insurance paperwork, the last thing you need is a time-consuming documentation process.
Yet, Subjective, Objective, Assessment and Plan (SOAP) notes are a key component of patient care. Without them, patient interactions go unrecorded—potentially causing a slew of communication and legal issues.
But there’s a way you can navigate the task without draining away valuable time and giving yourself a headache. With advanced practice management software like ChiroSpring, writing SOAP notes can be efficient, compliant, and incredibly easy.
Since every second counts in your busy chiropractic practice, you need all the time you can get. Keep reading to learn how you can use ChiroSpring to complete a SOAP note in only 15 seconds.
Step 1: Use Customizable Templates
This initial step is about making the software work for you. Without your own templates, notes can be inconsistent, time-consuming, and inaccurate. And without a defined format, new hires have to learn the varying styles of different doctors. A uniform template can tighten up your operations significantly.
ChiroSpring provides a library of over 50 chiropractic SOAP note templates, each designed to fit various patient needs. In addition, you may create your own template using a simple interface that supports various controls and even drag and drop. Think about the time you’d save with a designated template for scenarios like personal injury visits or quick daily SOAPS.
For comprehensive notetaking, ChiroSpring also offers the option to create a Super Note. This advanced tool allows you to customize a dynamic template that adjusts to each visit. Plus, it's easier to read, consolidating all elements of SOAP into one intuitive, fully customizable format.
Further, the Super Note eliminates the need for endless scrolling with collapsible sections for easy navigation. Moreover, it places control in your hands, allowing you to add or delete tests as needed.
Creating a customized Super Note allows for an organized and efficient approach to notetaking. This way, you can maintain thoroughness without compromising on detail or complicating your workflow.
Step 2: Eliminate Repetition with Auto SALT
Much like a repetitive strain disorder, repetition can cause a strain on your practice. Having to manually re-enter data is mind-numbing, tedious, and time-consuming work that can lead to burnout.
Fortunately, ChiroSpring provides the perfect remedy with its auto SALT (Same As Last Time) feature, also known as "ditto." As you write your SOAP note, ChiroSpring’s chiropractic practice management software automatically populates the note with information from the patient's previous visit. This saves you from typing the information out every single time you create a note.
Moreover, this automation extends beyond just notes; it applies to claims, too. Previous diagnoses and charges copy over, allowing you to change only what’s different for the current visit.
Additionally, auto SALT proves particularly powerful with ChiroSpring's Super Note feature. It can be used at every visit, ensuring a smooth transition of information from one appointment to the next. Plus, you can exclude individual sections, like exams, from auto SALT to prevent unnecessary repetition. However, during a re-exam, you can still pull data from the previous exam into the current notes with a single click.
Auto SALT saves you in other ways, too. It allows you to maintain consistent records, avoid data entry errors, and help patients understand their ongoing history and treatment plan. As a result, you’ll dramatically improve the quality and efficiency of patient care.
Step 3: Harness the Power of SOAP Macros
What elevates this system further is the power of SOAP macros, which are akin to custom shortcuts. These macros can auto-generate sentences or even entire paragraphs with a single click, further speeding up the note-taking process.
For example, suppose you frequently encounter patients with a specific condition like a herniated disc. With ChiroSpring, you can create a macro that instantly inputs a detailed explanation in your note. This not only saves you time but also ensures accuracy and consistency in your documentation.
In essence, SOAP macros work hand in hand with pre-populated notes to maximize efficiency, standardization, and customization in your notes. Together, they help you create high-quality, good SOAP notes in a fraction of the time they would normally take.
Step 4 (Optional): Consider Dictation
If you can speak faster than you can type, you have the option to remove typing from the process altogether. ChiroSpring’s SOAP notes feature supports dictation on any device, allowing you to communicate your thoughts quickly and naturally. Imagine “writing” your entire note with your mobile device using just your voice. Transforming dictation into documentation is right at your fingertips.
The Final Step: Save & Sign
If you're busy or have complex patient cases, you may not always have time to complete a SOAP note. No worries—ChiroSpring’s new Save & Sign feature allows you to save the progress of your notes. When the time is right, you can return to your note for review and finalization.
Choosing to sign off at a more convenient time, like during a break, is easier than juggling too much at once. This approach ensures you'll be more thorough and accurate in the review process. With a less rushed review process, you'll have peace of mind in case of an audit.
ChiroSpring: The Fastest Chiropractic SOAP Notes You’ll Ever Take
Creating efficient and effective SOAP notes isn’t just about documentation. It's about enhancing patient care, improving your practice's workflow, and ensuring compliance. But while SOAP notes are an essential tool in your repertoire, they shouldn’t be a stressful or time-consuming chore.
With ChiroSpring's robust and user-friendly platform, you can create SOAP notes in only 15 seconds. It empowers you with easy access to patient profiles, auto SALT, customizable templates, intuitive SOAP macros, and a streamlined system for capturing essential data. It effectively simplifies and speeds up the process without compromising the quality or detail of your notes.
To find out more about how ChiroSpring can enhance your practice, feel free to reach out to our team. We're here to help you streamline your practice for optimal efficiency and patient care.
SOAP Notes and Macros FAQs
How do you customize SOAP note templates for different patient scenarios while maintaining consistency and accuracy across notes?
SOAP note templates are tailored to patient needs and preferences, ensuring consistency and accuracy across notes for various scenarios such as personal injury visits or daily SOAPS.
How does the auto SALT (Same As Last Time) feature streamline the note-taking process?
Auto SALT populates relevant data from previous visits, saving time and preventing data entry errors.
What are SOAP macros, and how are they created?
SOAP macros are custom shortcuts that generate sentences or paragraphs with a single click, speeding up note-taking while maintaining accuracy and consistency. They can be created for frequently encountered conditions or procedures.
How does the option for dictation enhance efficiency?
Dictation allows practitioners to input notes verbally, saving time and effort.
References
ChiroSpring | Making the Best of SOAP Notes for Chiropractic Use. (2023, March 14). ChiroSpring. https://www.chirospring.com/articles/making-the-best-of-soap-notes-for-chiropractic-use
Podder, V., Lew, V., & Ghassemzadeh, S. (2022). SOAP Notes. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29489268/#:~:text=The%20SOAP%20note%20helps%20guide
Simple Chiropractic Notes: Producing Audit-Ready SOAP Notes with Ease. (2023, March 14). ChiroSpring. https://www.chirospring.com/articles/simple-chiropractic-notes-producing-audit-ready-soap-notes-with-ease
Williams, S. (2011). Potential Unique Causes of Burnout for Chiropractic Professionals. Journal of Chiropractic Humanities, 18(1), 86–93. https://doi.org/10.1016/j.echu.2011.09.003
Zayas-Cabán, T., Okubo, T. H., & Posnack, S. (2022). Priorities to Accelerate Workflow Automation in Health Care. Journal of the American Medical Informatics Association, 30(1). https://doi.org/10.1093/jamia/ocac197