Simple Chiropractic Notes: Producing Audit-Ready SOAP Notes with Ease

Chiropractors need to document the interactions and progress that they’re making with patients throughout their treatment plan. Taking these steps is also vital for the health of their chiropractic practice. That means documenting what occurs throughout every encounter into chiropractic notes. Chiropractors often fall behind with SOAP notes or do not document enough detail to withstand an audit.

Common Headaches When Dealing with Chiropractic Notes

Chiropractors are busy, and SOAP notes seem to take too much time. When auditors examine this work, it isn’t uncommon for chiropractors to have concerns regarding their documentation.

A chiropractor cannot rely on their memory 100% of the time when caring for their patients. SOAP notes play an integral part in serving their patients better, but they must have automation that speeds up the process.

Medical professionals already know about documenting SOAP notes. Skipping a letter in this acronym—Subjective, Objective, Assessment, and Plan—can lead to countless errors, headaches, and frustrations.

Here are a few examples.

Not Having Auto SALT: Chiropractors can get frustrated if their software does not auto SALT (Same As Last Time) essential information, such as subjective, charges, or diagnosis. The auto SALT feature means that chiropractors can automatically have the same chants, chart notes, and diagnosis as the patient’s last visit updated into their current visit. Having the ability to auto SALT an exam is even more important.

Matching charges (CPT codes) to what they document: Different actions have unique codes. Chiropractors use some codes frequently, but they use others only from time to time. CPT codes describe evaluations, tests, and other procedures that chiropractors perform on their patients. Chiropractors may charge for a service but forget to document its details in the SOAP note. The right software will streamline this process and provide tools to make the CPT code always follow the documentation pattern.

Wasting time retrieving and reviewing data: Reviewing old notes to obtain exam data is a waste of time. Chiropractors need a system that does this for them. Spending a half hour here or forty-five minutes there can ultimately cause chiropractors to waste several hours during a given week. Chiropractors want to spend more face-to-face time with their patients and less time keying in data.

How ChiroSpring Simplifies SOAP Notes

One of the most critical tasks that a chiropractor can perform is documenting their patients’ treatments. Writing SOAP notes is necessary but time-consuming. Using good chiropractic software can provide the tools that doctors need to write fast and compliant SOAP notes. Chiropractors must balance providing their patients with optimal care within an appropriate amount of time. Here are a few ways that ChiroSpring does this.

Auto SALT

Chiropractors can count on subjective information, charges, adjustments, and diagnoses all automating into SALT. They can simply click a button to copy a procedure from a patient’s previous visit to their current one. Because notes preload from the last visit, documentation is quicker, allowing chiropractors to save time and increase the number of patients they can see.

SOAP text

Chiropractors can create SOAP text associated with charges, so this text is appended to the SOAP when making changes. This feature can help them pass an audit. Chiropractors can also eliminate the time it takes to type by using SOAP Macros. For example, a single click can create a full sentence or paragraph. In addition to finding preloaded macros, chiropractors can use this feature to edit their own.

Charge groups

Chiropractors can create charge groups with ChiroSpring that automatically set diagnoses. This software automatically organizes every insurance charge, so offices can instantly identify every dollar that the clinic earns. In addition to creating charge groups, chiropractors can also edit individual charges, add notes about them, and re-submit charges with a single button click.

Single click changes

Exam dates are displayed in the current note and can pull into the current note with a single click. ChiroSpring makes exams easier than ever. Every patent exam has a touch interface, allowing chiropractors to pull a previous exam into the current note. Sample exams include those for range of motion, cranial nerves, muscle strength analysis, muscle tone analysis, orthopedic tests, and outcome assessments to name a few.

Document uploading

Chiropractors can run a 100% paperless office with ChiroSpring’s document uploading feature. For example, if a patient brings records from a previous provider, ChiroSpring supports uploading them in any form. Those documents automatically attach to the patient’s current record for quick and easy reference. Organize these documents by tagging them or putting them into custom folders. Chiropractors can also add notes to identify the contents of a specific document.

Conclusion

Incorporating ChiroSpring's chiropractic office software helps chiropractors create fast audit-proof SOAP notes. These chiropractic notes can streamline billing, intake, scheduling, and more. Contact one of ChiroSpring’s representatives today to learn more about this software and receive a quote.

ChiroSpring is an all-in-one practice management and EHR system built specifically for chiropractors to help them regain face-time with patients, spend less time on back-office tasks, maintain a limited staff, and save operational costs.

To see how ChiroSpring can help you simplify how you manage your practice, reach out to one of our specialists today!