Episode 9: Make Your SOAP Notes Great
Download your SOAP Note Quick Tip Sheet and SOAP Example by clicking here. In this episode we’ve gone over how to make your SOAP notes great, and we wanted to give you an easy to use resource to go along with todays show.
Let us know if you have any questions on this…we’d love to hear from you. If you want to get even more in-depth with SOAP notes, check out Episode 2 & 3 with Dr. Warren Jahn to dive deep on the intricacies of SOAP Notes.
Welcome to the ChiroPractice Pro Office. My name is Dr. Joshua Eldridge and I’m your host for today’s training: Making Your SOAP Notes Great.
As you know, there’re four parts to the SOAP note. Let’s just jump right into the subjective portion note.
Remember if you’re using a problem list, have a different subjective, objective, and assessment note for every problem that the patient presents with. So if the patient presents with neck and low back pain, and they’re not related, there should be two separate subjective, objective, and assessments for each problem.
The subjective portion of the note is what the patient tells you about the problem. We want to make sure that we get exact quotes from the patient in 2 to 3 sentence form to make sure what they say has been included in the note. Make sure what they say specifically pertains to their problem and not just general facts that they tell you about your day.
It’s also important to make sure that you know any changes since the last visit. So if they’ve stopped having ridiculous pain in their left leg, this would be important to note.
This objective is also the place that you want to add your outcome measurement tool scores like a Bournemouth questionnaire or a VAS. If you’re not using outcome measurement tools, these can be a great way to justify to insurance that you’re seeing real improvement with the treatment you’re providing. It also gives you a good tool to discharge the patient if they’re not improving.
And lastly add in the section you’re aggravating factors and the relieving factors that you discussed in your initial exam or the latest re-exam. This can be added in from your previous note or the initial exam and do not need to be re-created each and every visit.
Our next section is the objective portion of the soap note. Remember that the objective version is what you observe as the doctor. This is a place where we can know what has changed since last visit or what is change since the initial exam. Example if the range of motion has stayed the exact same for the lumbar spine then there’s no need to add this to the Objective portion of the note.
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