SOAP Notes: Is It Time for a Cleaning?
SOURCE: Dynamic Chiropractic – May 15, 2013
By James Edwards, DC
I have been planning for some time to write an article about how traditional SOAP notes do not fit chiropractic practice, and the unfairness of holding DCs to a model clearly created for and primarily applicable to medical physicians.
But Dr. Ronald Short beat me to the punch with his outstanding article:
“SOAP: A Chiropractic Perspective” [March 1, 2013 issue], in which he masterfully illustrated the problem. Hopefully, claim reviewers and documentation gurus will finally realize the difference between a chiropractic “assessment” visit and a chiropractic “treatment” visit.
As Dr. Short so ably pointed out,to require orthopedic and neurological testing on each chiropractic visit is the equivalent of requiring a medical doctor to perform blood tests after each antibiotic pill. I could not have said it better myself.
It is important to remember that doctors of chiropractic are unique because we wear two very different hats. First, we are physicians who examine and diagnose (assessment) the patient. Then, after doing so, we carry out our treatment plan by providing care (treatment) to the patient. Failing to realize the distinct difference between a chiropractic “assessment” visit and a chiropractic “treatment” visit places undue, unfair and unnecessary examination and documentation requirements on doctors of chiropractic, and it is time for it to stop.
This problem has been known for years, yet no one has been successful in sensitizing the chiropractic “powers that be” about this unfairness. The American Chiropractic Association’s Clinical Documentation Committee, during the process of authoring the third edition of the ACA Clinical Documentation Manual, attempted to directly address the issue by approving and submitting the following provision:
There are more articles like this @:
The new SOAP Notes Page and our
It is important to understand that the chiropractic physician has two responsibilities to their patients.