Chiropractor: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

SOAP notes are essential for effective patient care and documentation in chiropractic care. This guide provides detailed instructions for each section of a SOAP note, helping you understand the structure and content required for thorough documentation in the chiropractic context. By mastering SOAP notes, you can enhance patient care, ensure effective communication among healthcare providers, and maintain accurate medical records.

For specific examples, see our list of 10 Common Chiropractic SOAP Note Examples.

Subjective Section (S)

In a chiropractic SOAP note, the Subjective section (S) captures the patient’s self-reported information about their condition and symptoms. This section provides context for the chiropractor to understand the patient’s perspective and experiences. Here are the specific things that should go into the Subjective section of a chiropractic SOAP note:

Subjective Section (S) Components

1. Chief Complaint:

   • The primary reason the patient is seeking chiropractic care.
   • Example: "I have been experiencing neck pain and stiffness for the past week."

2. History of Present Illness/Injury:

   • Details about the onset, duration, and progression of the current condition.
   • Description of how and when the symptoms started.
   • Example: "The pain started after a minor car accident. The stiffness has gradually worsened."

3. Pain Description:

   • Location, intensity, quality, and duration of the pain.
   • Pain scale rating (e.g., 0-10 scale).
   • Example: "The patient reports a dull ache in the neck, rated as 5/10."

4. Functional Limitations:

   • Impact of the condition on daily activities and functions.
   • Specific tasks or activities that are difficult or impossible due to the condition.
   • Example: "The patient has difficulty turning their head and experiences pain during prolonged sitting."

5. Previous Treatments and Outcomes:

   • Information on any treatments the patient has previously received for the condition.
   • The effectiveness or outcome of those treatments.
   • Example: "The patient tried over-the-counter pain medications, which provided minimal relief."

6. Relevant Medical History:

   • Any relevant past medical conditions, surgeries, or injuries.
   • Family history if applicable to the condition.
   • Example: "No previous history of neck problems. The patient has a history of migraines."

7. Medications:

   • Current medications the patient is taking, including dosage and frequency.
   • Any recent changes in medication.
   • Example: "The patient is currently taking ibuprofen 200mg as needed for pain."

8. Patient Goals:

   • The patient’s goals and expectations from chiropractic care.
   • Example: "The patient hopes to relieve neck pain and improve mobility."

9. Other Relevant Information:

   • Any other information provided by the patient that may be relevant to their treatment.
   • Example: "The patient reports increased pain after working at a computer for long periods."

Tips:

• Use the patient’s own words when possible.
• Be thorough in documenting the patient’s history and symptoms.
• Ask open-ended questions to gather detailed information.

Example of a Subjective Section for Chiropractic Care

Objective Section (O)

In a chiropractic SOAP note, the Objective section (O) captures measurable, observable, and factual data obtained during the patient’s examination. This section provides concrete evidence of the patient’s condition and progress. Here are the specific things that should go into the Objective section of a chiropractic SOAP note:

Objective Section (O) Components

1. Vital Signs:

   • Record the patient’s vital signs such as blood pressure, heart rate, respiratory rate, and temperature if relevant to the session.
   • Example: "BP 118/76, HR 68, RR 14, Temp 98.4°F"

2. Physical Examination Findings:

   • Document the results of your physical examination, including inspection, palpation, and special tests.
   • Example: "Palpation reveals tenderness and muscle spasm in the cervical paraspinal muscles."

3. Range of Motion (ROM):

   • Measure and record the range of motion for relevant joints or body parts.
   • Example: "Cervical flexion: 30 degrees (normal: 45 degrees), Cervical extension: 20 degrees (normal: 45 degrees)"

4. Orthopedic Tests:

   • Document the results of any orthopedic tests performed.
   • Example: "Positive Spurling's test on the right side."

5. Neurological Examination:

   • Include findings from any neurological assessments, such as reflexes, sensation, and muscle strength.
   • Example: "Decreased sensation in the right C6 dermatome. Muscle strength 4/5 in the right upper extremity."

6. Posture and Gait Analysis:

   • Assess and record the patient’s posture and gait.
   • Example: "Forward head posture observed. Gait is normal."

7. Diagnostic Tests:

   • Include results of any diagnostic tests relevant to the chiropractic session, such as imaging reports or lab results.
   • Example: "X-ray shows mild degenerative changes in the cervical spine."

Tips:

• Be precise and factual in your documentation.
• Include only measurable and observable data.
• Use standardized scales and measurements where applicable.

Example of an Objective Section for Chiropractic Care

Assessment Section (A)

In a chiropractic SOAP note, the Assessment section (A) synthesizes the information gathered in the Subjective and Objective sections to provide a clinical judgment about the patient’s condition. This section includes the chiropractor's professional interpretation, diagnosis, and the patient’s progress and response to treatment. Here are the specific things that should go into the Assessment section of a chiropractic SOAP note:

Assessment Section (A) Components

1. Diagnosis:

   • Provide a clinical diagnosis based on the subjective and objective findings.
   • Example: "Cervical strain with associated muscle spasm."

2. Clinical Impression:

   • Include your clinical interpretation of the patient’s condition.
   • Example: "The patient’s symptoms are consistent with a cervical strain, likely exacerbated by poor posture and prolonged computer use."

3. Functional Limitations:

   • Document the impact of the patient’s condition on their daily activities and functional abilities.
   • Example: "The patient has significant limitations in neck mobility and experiences pain during prolonged sitting."

4. Patient Progress:

   • Comment on the patient’s progress since the last visit, if applicable.
   • Example: "Since the last visit, the patient reports a slight reduction in pain but continues to experience stiffness."

5. Prognosis:

   • Provide an outlook on the patient’s recovery based on their condition and response to treatment.
   • Example: "With continued chiropractic care, the patient has a good prognosis for reducing pain and improving mobility within 4-6 weeks."

6. Goals:

   • Set specific, measurable, achievable, relevant, and time-bound (SMART) goals for the patient’s treatment.
   • Example: "Short-term goal: Reduce pain to 3/10 within two weeks. Long-term goal: Restore full range of motion and strength in the neck within six weeks."

Tips:

• Be clear and concise in your clinical judgment.
• Use evidence-based reasoning to support your diagnosis and clinical impression.
• Set realistic and measurable goals for the patient.

Example of an Assessment Section for Chiropractic Care

Plan Section (P)

Plan Section (P) Components

1. Treatment Plan:

   • Specific interventions that will be implemented to address the patient’s condition.
   • Example: "Chiropractic adjustments to the cervical spine."

2. Therapeutic Exercises:

   • Detailed description of the exercises prescribed, including the type, frequency, duration, and any progression plans.
   • Example: "Neck strengthening exercises, 3 sets of 10 reps, twice daily."

3. Modalities:

   • Any therapeutic modalities that will be used, such as heat, ultrasound, or electrical stimulation.
   • Example: "Apply heat therapy to the neck for 15 minutes before exercises."

4. Patient Education:

   • Information and instructions provided to the patient to help them manage their condition and prevent further injury.
   • Example: "Educate the patient on proper ergonomics and posture correction techniques."

5. Home Exercise Program (HEP):

   • Exercises and activities prescribed for the patient to perform at home between therapy sessions.
   • Example: "Home exercise program includes stretching exercises for the neck and upper back, to be performed twice daily."

6. Referral:

   • Any referrals to other healthcare professionals or specialists if necessary.
   • Example: "Refer the patient to a physical therapist if no improvement is seen in four weeks."

7. Follow-Up:

   • The plan for subsequent visits, including the frequency and duration of follow-up appointments.
   • Example: "Schedule follow-up appointments twice a week for the next four weeks to monitor progress and adjust the treatment plan as necessary."

Tips:

• Be specific and detailed in your treatment plan to ensure clarity and adherence.
• Tailor the plan to the individual needs and goals of the patient.
• Ensure that the patient understands their role in the treatment plan, especially for home exercises and self-care.

Example of a Plan Section for Chiropractic Care

This detailed information in the Plan section ensures that the patient receives a comprehensive and personalized treatment strategy, and helps track progress and outcomes effectively.

AI-Assisted Documentation for Chiropractic Care

As of 2025, 66% of healthcare providers use AI tools in their practice. AI scribes and ambient clinical intelligence can significantly reduce documentation burden for chiropractors while accurately capturing spinal assessments and adjustment details.

How AI Can Help with Chiropractic Documentation

• Ambient listening: AI captures patient conversations and automatically structures findings
• Measurement recognition: Accurately captures ROM values, orthopedic test results, and pain scales
• Adjustment documentation: Records spinal segments treated, techniques used, and patient response
• Efficiency: Reduces documentation time by up to 50-75%

Chiropractic-Specific AI Considerations

What AI captures well:

• Patient-reported symptoms and pain descriptions
• Treatment plan discussions and home care instructions
• Exercise parameters and frequency recommendations
• Follow-up scheduling and referral discussions

What requires careful review:

• Range of motion measurements (verify exact degrees)
• Spinal segment levels (C1, L5, etc. - verify accuracy)
• Orthopedic and neurological test results (positive/negative findings)
• Laterality (left vs. right sided findings)
• Adjustment techniques and force descriptions

Tips for Using AI with Chiropractic Documentation

1. Speak segment levels clearly: "Subluxation identified at C5-C6 with right lateral flexion restriction"
2. Verbalize ROM precisely: "Cervical rotation is thirty degrees to the right, forty-five degrees to the left"
3. Dictate orthopedic tests explicitly: "Spurling's test is positive on the right, reproducing radicular symptoms"
4. Confirm adjustment details: "Performed diversified adjustment to T4-T5 with audible release"

For more details, see our complete AI-Assisted Documentation Guide.

Telehealth Chiropractic Documentation

Telehealth for chiropractic care has significant limitations since spinal manipulation and manual therapy require hands-on treatment. However, telehealth has valuable applications for consultations, exercise instruction, and progress monitoring. Per CMS 2026 guidelines and HIPAA telehealth requirements, specific documentation requirements apply.

Appropriate Telehealth Uses in Chiropractic

Telehealth visits are appropriate for:

• Initial consultations and history-taking
• Follow-up assessments between adjustment visits
• Home exercise program instruction and progression
• Ergonomic assessments of home or work environments
• Patient education on posture and self-care techniques

Telehealth Limitations for Chiropractic

Critical limitations to document:

• Spinal adjustments: Cannot be performed via telehealth
• Palpation: Unable to assess vertebral motion, muscle spasm, or tenderness
• Orthopedic testing: Many tests require manual examination
• ROM assessment: Limited to patient-demonstrated active movements
• Neurological examination: Reflex and sensory testing not possible

Example Telehealth Chiropractic Documentation

For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.