Crafting a SOAP note is now effortless with the SOAP Wizard! Dive into the comprehensive guide below to unlock all the essentials and streamline your note-taking process like never before. 🪄💪
Before you start on your SOAP note, you first need to create an encounter. Luckily, encounters are automatically created when a patient checks in for their appointment, so once the patient has checked in, you’re ready to cruise through your note! 😎
This guide is comprehensive, covering every aspect of taking an initial note using the SOAP Wizard. It is a lot of information, so we recommend taking it one piece at a time! This article will cover everything there is to know about using ChiroUp's SOAP Wizard— you'll be an expert in no time!
Click below to explore each piece of an initial SOAP Note:
SUBJECTIVE
The Subjective Wizard is where you will review the subjective information provided by the patient in the Chief Complaint Survey (CCS).
If the patient has completed the CCS before their visit or at check-in (either on their device or the kiosk), the survey results will automatically populate in the Subjective Wizard, as shown below.
If the patient has not completed the CCS or if not all complaints were reported, don't worry! Just click the + button to add a new complaint. From there, you can either send the CCS to your patient via text or email again, or complete it directly on your screen.
After you've ensured that all complaints are included, review the subjective information. Since all subjective content is populated from the CCS, you do not need to take further action within the Subjective Wizard.
However, if you want to add any additional notes regarding the subjective information not captured in the CCS, you can do so in the Notes box at the bottom of the page.
Once you are satisfied with the Subjective portion, proceed to the Assessment Wizard by clicking the next arrow or by selecting Assessment in the left side panel of the Encounter.
ASSESSMENT
The Assessment Wizard is where you select the patient’s diagnosis. Click + Condition to select from ChiroUp's condition library. Search for the condition by name or region.
💡Pro-tip:
Use our short cut keys (C, T, L, SI) to quickly select common joint dysfunction disorders— Cervical Segmental Joint Restriction, Thoracic Segmental Joint Restriction, Lumbar Segmental Joint Restriction, and Sacroiliac Joint Dysfunction, respectively.
Once a diagnosis is selected, you have the option to indicate ICD codes by either using the search bar or selecting an associated billing code.
(hint: click the play icon to access that condition's protocol in a separate tab. click this icon anywhere you see it while taking a SOAP note to open additional clinical information and tips.)
Note!
Indicating an ICD code is only necessary if you will be billing insurance. It's at the provider's discretion to include ICD codes in the SOAP note (as there are other ways to indicate them), but doing so in the Assessment Wizard streamlines the process.
💡 Pro-tip:
Toggle on PRN to designate the complaint for treatment as needed, and as a result, the SOAP Wizard will not generate a care schedule for the patient’s complaint.
Once you are satisfied with the Assessment portion, proceed to the Objective Wizard by clicking the next arrow or by selecting Objective in the left side panel of the Encounter.
OBJECTIVE
The Objective Wizard is where you will document the results of any tests performed and observations made.
As you progress through the Objective Wizard, you'll notice that each of the tests and information is populated based on the diagnosis selected in the Assessment Wizard.
💡 Pro-tip:
You can edit the information that will populate in the Objective Wizard based on a diagnosis within that condition's Condition Reference.
Joints:
The Joints panel is where you will indicate any region-specific joint restrictions.
- You can further define the joint as the right or left side. (hint: For the spinal region, define left or right after making your selection)
- You can navigate through and add different regions via the tabs at the top of the panel.
- To remove any unnecessary region, use the Remove region button at the bottom.
Range of motion:
The Range of Motion panel is where you will indicate the region-specific range of motion test results.
- Mark range of motion indications by clicking directly on each line.
- Select the Pain? bubble next to indicate pain during each test.
- You can navigate through different regions via the tabs at the top of the panel.
- To remove any unnecessary region, use the Remove region button at the bottom.
Myofascial:
The Myofascial panel is where you can indicate myofascial findings.
- Use the Add muscles drop down to select the appropriate muscles (you can narrow down first by region).
- Mark indications relating to each muscle— including left or right.
- To remove a muscle from the panel, click the x next to the muscle you want to delete.
- Click the Accept suggestions button to automatically check the boxes Tender, TP, HPN for each muscle.
Orthopedic:
In the Orthopedic panel, you can specify orthopedic evaluation results.
- Use the Add evaluations drop down to select the appropriate evaluations (you can narrow down first by region).
- Mark positive or negative results— including left or right side.
- Delete any unnecessary evaluations with the corresponding x and add any additional evaluations using the bar at the bottom.
- Click Accept suggestions to automatically mark tests that are typically positive or negative for that specific condition. (suggested test results can be viewed and modified in that condition's condition reference).
Neurological:
The Neurological panel is where you will indicate neurological test results.
- Each test is defaulted to Not Assessed.
- If you perform any neurologic tests, mark results as either Normal or Abnormal.
- The All Normal button will automatically mark all tests as Normal.
- Reporting an abnormal test will allow you to document specific abnormal findings:
After completing the Neurological panel, you've successfully navigated through the Objective Wizard, congratulations!! 🥳 You're almost to the end!
Once you are satisfied with the Objective portion, proceed to the Plan Wizard by clicking the next arrow or by selecting Plan in the left side panel of the Encounter.
PLAN
The Plan Wizard is where you will document the patient treatment plan.
Evaluation & Management:
The Evaluation & Management section is where you will select the exam or re-exam performed during the visit.
💡 Pro-tip:
The Plan Wizard is integrated with the billing process:
Each selection within the Evaluation & Management, Treatment, and Rehab sections has its own corresponding service code. When you click on any suggestion, it will both highlight green (indicating selection) and add a 1 in the corner (indicating one billable unit). Clicking the selection again will increase billable units. To cycle back to an unselected, non-billable unit, continue clicking the item until it is no longer highlighted.
(You can also associate billing codes to selections within the Imaging & Tests, Modalities, and Supplement & Supply sections within their respective databases.)
Any indicated billable units within the Plan Wizard can be easily applied later on during the billing process. To learn what service codes are associated with each selection, click here.
Imaging & Tests
The Imaging & Tests section is where you will add any imaging and test orders. Simply click the RX button, input the test details (including the option to associate a billing code), and save. The test you order will populate into the panel already selected with one billable unit indicated.
Test can also be added and results uploaded in the Tests detail module.
Note!
Prior to ordering a test, you will need to populate your Tests and “Providers & facilities databases.
Treatments:
The Treatments section is where you will indicate treatments conducted at this visit. Similar to Evaluation & Management, each selection in the treatments section has its own associated billing code. (Click here to see a breakdown ). Depending on what you selected within the Objective Wizard joints panel, some manipulation selections will auto-populate. Select any other treatment performed.
Modalities:
The Modalities section is where you can prescribe modalities to be completed during that visit. Click the RX button to open the modality screen. Use the + icon to add a modality. Enter relevant details and click Add.
Remember to save the modality (using the floppy disk icon). Only click the Complete button if the modality has been completed, as this action will indicate in your note that the modality was completed. (You can also indicate that a modality has been completed in the modalities detail module).
Supplements & Supplies:
Under Supplements & Supplies, add any supplements and supplies ordered.
Click the RX button to select with supplements or supplies from your database that you would like to add.
Note!
Prior to ordering a supplement or supply, you will need to populate your Supplements & supplies database.
Rehab:
The Rehab section will indicate prescribed exercises. Click the RX button to view and add exercises.
Ensure that the correct rehab indication is made in the Plan Wizard. (similar to the evaluation and management section, each selection has its own associated service codes. Click here to see a breakdown).
Review or add any exercises— including populating the In-office section as necessary.
💡 Pro-tip:
Here are some different ways to populate the “In-Office” section:
- The copy icon in the bottom corner of each exercise will copy existing exercises to the in-office section
- The “Add” button to add new
- Drag and drop to move an exercise from one section to another
Remember to save the exercises (using the floppy disk icon). Only click the Complete button if the exercises have been completed in office, as this action will indicate in your note that the exercises were performed. (You can also indicated completed exercises exercises detail module).
Extra Plan Details:
- At the top of the Plan Wizard you can indicate whether the patient is in Active Treatment or Maintenance care. This information will also display in the purchase and helps users decide the appropriate modifiers to use based on the treatment type.
- Click the Import Charges button to easily import the charges you've indicated in the Plan Wizard into the corresponding patient purchase.
Once satisfied with the Plan portion, proceed to the Schedule & Goals section by clicking next arrow or by selecting Schedule & Goals in the left side panel of the Encounter.
SCHEDULE & GOALS
The Schedule & goals section of your SOAP Note is where you will document a visit schedule, the next re-evaluation, the outcome goal, and the next requested visit.
- Visit schedule: documents your planned care schedule for the patient's active complaints
- Visit number: records which visit number this encounter falls on, you shouldn't need to edit this number unless the care plan has been interrupted, and you need to correct the visit schedule.
- Next re-evaluation: determines at what upcoming visit the patient will complete a re-exam survey upon check-in
- Outcome goal: documents what percent of improvement you expect the patient to make
- Next requested visit: shows on the patient's corresponding appointment and purchase panels so staff know when to schedule the patient's next visit
The side panel also gives a snapshot of the patient's care schedule: next visit type, visit number, life time visits, next re-eval, and a button to start a new care plan.
💡Pro tips:
- It is recommended that you click the Start new care plan button only when a patient is starting a new care plan with new active complaints.
- The visit schedule and outcome goals auto-populates based on your default preferences set in the Condition Reference.
Once satisfied with the Schedule & goals, proceed to the SOAP output by clicking next arrow or by selecting SOAP in the left side panel of the Encounter.
SOAP NOTE OUTPUT
And lastly, we have your completed SOAP note! The note is a synopsis of the information collected throughout each wizard.
Scroll through and review each section, and if needed, add any additional detail (each field is a free text box!).
If you’d like to add an additional section to your note, scroll to the bottom and enter the section name in the bottom text bar and then click Add Section. Then, you can enter the additional information before saving and signing.
Once the provider has reviewed each portion of the note, click Save & Sign icon and…
Voila! Your SOAP note is finalized! Virtual high five— amazing job!!!! 🙌 🎉😉
Jump to each Wizard's article for further information!
Subjective Wizard Assessment Wizard Objective Wizard Plan Wizard
💡Pro tip:
Finished your note and ready to give the patient their condition report? You can do that right from the Communications detail module!