Why are so many of you looking for good SOAP documentation? It’s because many chiropractors are being audited, and the first thing an audit looks for is the notes.

An audit, however, is not the only reason to have great notes — a complaint to a state board will also require you to have proper documentation for your defense.

You need great documentation for these reasons, but you should also want it to have a good historical condition of your patient.

Look for specific ways to help your practice create a great compliant note and adjust the number of patients you need to.

How do you do this?

The answer used to be a paper travel card with check boxes for every possible symptom, subluxation, palpation findings, treatment, or therapy. The doctor would check the boxes and write a few notes about what the patient said.

This worked OK for internal use, but when asked for notes, the doctor didn’t want to send in the check boxes and scribbles, so he would transcribe the notes into a narrative format that someone could read.

It might’ve solved the in-office issue of taking notes, but now he had to stay longer to clean up the notes. The more patients you saw, the longer you had to work — creating more fatigue and time away from the family.

EHR may be the answer. Not every EHR can produce the notes you are looking for or save you time in the office, therefore, you need to know what to look for.

Regulations to follow

Medicare has very specific guidelines for notes. As per the Medicare Benefit Policy manual, chapter 15, under section 240.1.1, Chiropractic Services, all visits need a specific documentation:

1. History: Review of chief complaint; changes since last visit; system review if relevant.

2. Physical exam: Exam of area of spine involved in diagnosis; assessment of change in patient condition since last visit; evaluation of treatment effectiveness. Documentation of treatment given on day of visit.

Section 240.1.4 clarifies how Medicare wants you to document about the location of subluxation.

“The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. This designation is made in relation to the part of the spine in which the subluxation is identified: There are two ways in which the level of the subluxation may be specified. The exact bones may be listed, for example: C5, C6, etc. The area may suffice if it implies only certain bones such as: Occipito-atlantal (occiput and C1 (atlas)), lumbo-sacral (L5 and Sacrum), sacro-iliac (sacrum and ilium).

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