Chiropractic SOAP Note (Follow-Up Visit)

Visit Information

Date of Service: [date of service]

Patient: [patient name and identifier]

Clinician: [clinician name and credentials]

Visit Type: Follow-up visit

Visit/Episode Context: [visit number or episode start date] (Include if available.)

Subjective

Chief Complaint: [one-line, patient-centered reason for today's visit; include brief direct quote if it clarifies complaint or severity]

Interval History: [changes since prior visit for treated complaint(s): current pain level with numeric rating and comparison to last visit; symptom quality and pattern changes; aggravating/relieving factors; radiation or paresthesias if present; functional status with concrete anchors including ADL/work/sleep changes]

Response to Prior Treatment: [patient-reported immediate and short-term response to last treatment; any adverse effects; adherence to home exercises/self-care; barriers to adherence if relevant]

Interim Events: [new injury/trauma/exacerbation; new complaints; medication changes; care received elsewhere] (Include only if applicable; omit entire field if nothing to report.)

Safety Screen: [pertinent positive/negative red flags: new/worsening neuro symptoms; bowel/bladder changes; constitutional symptoms] (Include only when clinically relevant; omit entire field if no concerns.)

Objective

General: [overall appearance; observed distress level; gait quality; guarding; vitals if obtained or clinically indicated]

Focused Exam: [posture/antalgia observations; palpation findings with location and severity; segmental motion/joint dysfunction findings with specific levels; ROM with degrees or qualitative descriptors and pain provocation; neurologic screening and provocative tests if clinically indicated] (Document involved region(s) sufficient to assess change and treatment effectiveness.)

Comparison to Prior Visit: [1–3 trendable findings demonstrating improvement/no change/worsening with specific anchors compared to last visit]

Subluxation/Dysfunction Findings (P.A.R.T.): [Pain/tenderness location and severity; Asymmetry/misalignment at specified level; Range of motion abnormality; Tissue/tone changes] (Include when required by payer or clinic policy to support working diagnosis and treated levels.)

Assessment

[List diagnoses addressed today with region/level specificity. For each active problem, state: diagnosis, current status (improving/unchanged/worsening), and brief supporting evidence from today's S and O findings. Note progress toward functional goals. Include care phase classification (active/corrective vs maintenance) with rationale when required by payer.]

Plan

Treatment Performed Today:

• Spinal Manipulation/Adjustment: [region(s) and specific level(s) treated; technique category; patient position; modifications/precautions if applicable]
• Adjunctive Therapies: [soft tissue techniques with location/duration; therapeutic exercise instruction; modalities with parameters] (Include details sufficient to support billed services.)

Patient Response: [tolerance to care; immediate response including pain or ROM change; any adverse events and instructions provided] (If response unknown, document as such.)

Ongoing Plan: [visit frequency until next re-evaluation; home exercise program with specific exercises or handout reference; activity modifications and self-management strategies; date or visit count for next re-evaluation]

Referral/Escalation: [referral made; imaging requested; urgent care instructions] (Include only if applicable; omit entire field otherwise.)

Clinician Signature: [name, credentials, and signature attestation]

Date/Time: [date and time of signature]

(When information ordinarily necessary for safety or medical necessity is not assessed, explicitly document the reason. Distinguish patient-reported information from clinician observations throughout. If using scribe or AI transcription, clinician must attest to review and authentication of content.)