FAST COMPLETE PATIENT (CHART) S.O.A.P. NOTES

FAST COMPLETE PATIENT (CHART) S.O.A.P. NOTES
{these soap note formats has been, modified & published used by permission from Dr. Loc Nguyen, D.C.}
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DrBackman.com Chiropractic; lawrence dieter, d.c.
1171c Toro St. San Luis Obispo, CA 93401
(805)544-0237

In Published articles in the CCA (California Chiropractic Journal) and the W.C.A. (World Chiropractic Alliance; The Chiropractic Journal) last year, two points were brought by the legal experts in this field:
1. "Picture your current S.O.A.P. notes magnified 25 times and shown to a jury in court, Now how do you feel about your chart notes?"
2. (Given you have an organized system of soap notes.) "The More an opposing attorney needs to ask you questions to clarify your chart notes, the more you, the doctor, appears as an expert." (Always Remember to Sign Your Chart Notes & the Patient.)

LET ME SIMPLIFY YOUR LIFE &
GIVE YOU AN ORGANIZED SYSTEM OF SOAP NOTES

S = SUBJECTIVE, O = OBJECTIVE, A = ASSESSMENT, P= PLAN
Here is the concept: at the top of the page is the usual header info, pt. name, date, d.o.i.
then there are 23 "office visit squares" on each side of the page. and I realize that each individual will want to modify this format according to his/hers' own chiropractic practice.

or you can click on the link "...print example, then highlight (left click-hold drag),
right click, select copy, open a new page in your word processor,
right click, select paste, modify, print.
(sorry for the numerous steps, but word wants to alter the format for some reason. I guess I could call and talk to bill gates about this)

you may need to adjust the size of your font size so there is 7 lines per box
to do this, in IE, click on "view" and select font/text size.
Or you can go to the print page, copy the entire page to the clip board, paste into a new word document and reformat according to your needs.

key & Office Visit S.O.A.P. Note
Print Example #1.
Print Example #2
Print Example #3
Print Example #4 (my favorite, you'll see why) Soap notes in under 15 seconds by Dr. G.E. Nielsen, www.DocNielsenStuff.com

KEY to S.O.A.P. notes (#1)

Cervical, Thoracic, Lumbar
Slight, Mild, Moderate, Severe
Pain - Occiput to sacrum
Muscle Spasm - Occiput to Sacrum
Subluxation - Occiput to Sacrum
Range of Motion Adjusted Areas
Pelvic Def. (leg length) P.T. Modalities

-------------------------------------------------------
month/date           patient signature

C -I.S.W.R T -I.S.W.R. L -I.S.W.R.
Si Mi M S   Si Mi M S   Si Mi M S
P-o1234567-123456789101112-12345-S
M-o1234567-123456789101112-12345-S
S -o1234567-123456789101112-12345-S
R.o.M. /\ \/ C-T-L   A -O/C/T/L/S/Ex
P.D.rt./lt.       T-H/I-E-U-M-D

KEY to S.O.A.P. notes (#2)
Cervical/Thoracic/Lumbar; Improved/Same/Worse/Resolved; Slight/Mild/Moderate/Severe
Pain Areas: Cervical, Thoracic, Lumbar, Pelvic, Extremity, Wrist, Shoulder
Muscle groups: Paraspinal, trapezus, deltoid, levator scapulae, rhomboid, quadratus lumborum, hamstrings, calf muscle group, right and left sided sciatica
Subluxation - Occiput to Sacrum
Range of Motion
Adjust Areas, Pelvic Deficiency (leg length);
Physiotherapy Modalities: Ultrasound, Myopulse, Interferential, Massage, Heat Exercise

-------------------------------------------------------
DATE:

C-   I. S. W. R      Si Mi M S
T-   I. S. W. R.     Si Mi M S
L-   I. S. W. R.     Si Mi M S
Ex- I. S. W. R      Si Mi M S
Pain Area: C, T, L, P, Ex, Wr, Sho, Knee, F-arm
Muscle Groups: Paraspinal C T L. Trap, Delt,
          Lev-Scap, Rhom, Quad.Lumb Quad, Ham, Calf
           Rt-Lt Sciatica
Sublux. -O1234567-123456789101112-12345-S
Disability Status: Yes No
                               With--Without Limitations
R.o.M.       C ¯     T ¯      L ¯       Ex ¯
Adjust       O – C – T – L - S/P - Ex
P.D right. - left
Modalities: Ultra, Myo, Inf, Mass, Heat, Exercise

S.O.A.P. Notes Example #3
Date	Pain Tenderness Spasm Radiating Inflammation Paraesthesia Weakness Dec. R.O.M. Stiff/Tight Posture	Manipulation Neur.Mus.ReEd +Ortho. Test +Neuro. Test Deep Tis. Mass. Ultrasound Traction Heat Cryo Tx. Elect.Mus. Stim.	Exacerbated Improving Chronic/Acute Constant Frequent Intermittent Occasional Severe Moderate Slight Mild	T.M.J. Occiput C 1234567 T 123456789101112 L 12345 Sac./Coccyx/Pelvis Supports Supplements Other:	Prognosis: Good Unable To Determine Guarded Comments:

LET ME SIMPLIFY YOUR LIFE & GIVE YOU AN ORGANIZED SYSTEM OF SOAP NOTES

LET ME SIMPLIFY YOUR LIFE &
GIVE YOU AN ORGANIZED SYSTEM OF SOAP NOTES