When we think of documenting a SOAP note, we need to be sure that we connect all the dots. One of the biggest problems I see in the many chiropractic records I review is that the treatment is not justified by the findings.
And it’s easily corrected.
If you perform an adjustment/CMT at C3, what is the justification for that? The simple answer is restriction/fixation/subluxation at C3. If you perform an adjustment/CMT to the right shoulder, the justification would be restriction/fixation/subluxation of the right shoulder. You also want to be sure there is asymptomatic complaint and diagnosis that corresponds to the finding. Think of it this way: symptom + finding + diagnosis = justification for treatment.
Manual Therapy is another one that comes up frequently. CPT tells us that manual therapy (97140) is performed in order to increase functional performance,increase range of motion, decrease inflammation and reduce muscle spasm. That tells us that our objective findings should mention some type of decrease in functional performance, decrease in range of motion, increase in inflammation or the presence of muscle spasms.
Therapeutic Exercise (97110)
CPT tells us that therapeutic exercises are performed in order to develop strength and endurance, range of motion and flexibility. The justification that we should document for this should mention some type of abnormality of strength and endurance, range of motion or flexibility.
When we document properly and understand that the Why supports the What, we’re one step closer to being…