Assessment: What’s Your Thoughts?

Welcome back to our series on documentation and patient notes. Don’t forget to check out our other SOAP note posts…you can check them out here:

So what’s the purpose of the Assessment?

We see so many times that it goes like this:

Patient tolerated treatment well and will continue on with treatment plan.

But is this a complete assessment of what’s going on in your patient’s life and treatment plan?

ChiroPractice Pro wants you to be prepared to take great notes and we’ve brought in famed documentation expert Dr. Warren Jahn to give us more information on what makes the assessment portion of your note so important!

In A Nutshell

Take the exam and history portion of the note, and describe what you feel is happening with you patient’s treatment and progress. Draw your conclussions from what you see and take into account the following information:

  • Patients functional limitations
  • Impairments
  • Compliance to your instructions
  • Changes to the treatment plan

It’s a critically important part of the SOAP note because it explains and interprets the information collected during the examination and links it directly to your treatment plan. Here’s what Dr. Jahn says about the assessment:

The assessment is the section where the provider draws some conclusions from the information gathered during the examination portion of the note or visit. It takes into account the patient/client’s functional limitations and impairments, compliance and the changes to the treatment plan.

The assessment is important in documentation because it explains/interprets the information collected during the examination and links directly into the treatment plan determined by the provider.

Basically, it is the “why” or rationale portion of the documentation explaining why a particular treatment plan or daily encounter procedure has been chosen as most appropriate for the patient. I should be able to go to any note and know exactly what was prescribed, how the patient is progressing and where you want to go on the next encounter.

Assessing our Assessment

So the point of the Assessment is that I should be able to come into your office (as a fellow chiro) read your assessment, and know exactly how to continue on with care with your patients. If it’s not up to this standard, then you might want to consider updating the way you write your assessment so you get the most out of your notes!

We’re here to help in any way, so let us know if we can help. Just leave a comment below if you have a question for us!