SOAP Note
Patient Name
First Name
Last Name
Subjective
Patient presents today for continued care for their:
Neck
Mid Back
Lower Back
Right Shoulder
Left Shoulder
Right Hip
Left Hip
Right Knee
Left Knee
Neck, Shoulder, and Lower Back
Neck, Lower Back and Right Hip
Neck, Lower Back and Left Hip
Lower Back and Right Hip
Lower Back and Left Hip
Lower Back and Right Knee
Lower Back and Left Knee
The patient rates the pain on the VAS as a:
0
1
2
3
4
5
6
7
8
9
10
Following their last treatment, the patient states that the pain has:
Increased
Decreased
Stayed the same
Objective
Palpation of the areas above reveals:
Hypertonicity
Trigger Points
Muscle Spasms
Hypertonicity, Trigger Points, and Muscle Spasms
Segmental dysfunction noted at:
C1
C2
C3
C4
C5
C6
C7
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
C2,3,4,T5,6,9,L4,5
Assessment
ASSESMENT: Improving as expected due extent and / or nature of injury or complaint.PHASE OF CARE: Acute.PROGRESS: As Anticipated.DIAGNOSIS: Same as previous encounter.
ASSESMENT: Improving as expected due extent and / or nature of injury or complaint.PHASE OF CARE: Rehab.PROGRESS: As Anticipated.DIAGNOSIS: Same as previous encounter.
ASSESMENT: Not improving as expected due extent and / or nature of injury or complaint.PHASE OF CARE: Acute.PROGRESS: As Anticipated.DIAGNOSIS: Same as previous encounter.
Plan
CMT CHIROPRACTIC MANIPULATIVE THERAPY / SEGMENTAL DYSFUNCTION LEVELS (VSC / SD levels listed above). [x]98941. TECHNIQUES: [x] Diversied Technique POST TREATMENT: Treatment (TX) tolerated well. Symptoms less. Range of Motion (ROM) increased / improved. SHORT TERM GOALS: reduce pain and restore normal joint function and muscle balance. LONG TERM GOALS: restore function independence and tolerance to normal activities of daily living. FREQUENCY: 1 visit per week.
CMT CHIROPRACTIC MANIPULATIVE THERAPY / SEGMENTAL DYSFUNCTION LEVELS (VSC / SD levels listed above). [x]98941. TECHNIQUES: [x] Activator. POST TREATMENT: Treatment (TX) tolerated well. Symptoms less. Range of Motion (ROM) increased / improved. SHORT TERM GOALS: reduce pain and restore normal joint function and muscle balance. LONG TERM GOALS: restore function independence and tolerance to normal activities of daily living. FREQUENCY: 1 visit per week.
Date
/
Month
/
Day
Year
Date
Signature
Submit
Should be Empty: