10 Common Chiropractor SOAP Note Examples

Create Your Chiropractor SOAP Note in 2 Minutes

Start with 3 free SOAP notes. No credit card required.

Type Your NoteRecord Note

List of cases

1. Low Back Pain
2. Cervical Spine Dysfunction
3. Sciatica
4. Thoracic Spine Pain
5. Whiplash Injury
6. Headaches
7. Sacroiliac Joint Dysfunction
8. Shoulder Impingement
9. Plantar Fasciitis
10. TMJ Disorders

1. Low Back Pain

Description

The patient presents with acute low back pain following improper lifting technique, seeking chiropractic care for pain relief and improved function.

SOAP Note

Patient Name: James Mitchell

Date of Visit: 09/01/2024

Subjective

James Mitchell, a 42-year-old male, presents with acute low back pain after lifting a heavy box at work 3 days ago. Reports sharp, constant pain rated 7/10, localized to L4-L5 region with occasional radiation to left buttock. Pain increases with forward bending and prolonged sitting, improves with lying down. Denies numbness or tingling in legs. No loss of bowel/bladder function. Sleep disturbed due to pain. No previous history of back injury. Currently taking over-the-counter ibuprofen with minimal relief.

Objective

• Vital Signs:
  • BP: 128/82 mmHg
  • HR: 76 bpm
  • RR: 16/min
• Postural Analysis:
  • Left lateral shift
  • Increased lumbar lordosis
  • Antalgic lean away from affected side
• Range of Motion (Lumbar):
  • Flexion: 30° (limited by pain)
  • Extension: 15° (limited by pain)
  • Left Lateral Flexion: 20°
  • Right Lateral Flexion: 15°
• Orthopedic Tests:
  • (+) Straight Leg Raise at 45° left
  • (+) Kemp's Test left
  • (-) Slump Test
• Palpation:
  • Muscle spasm in left paraspinal muscles L3-S1
  • Tenderness over L4-L5 facet joints
  • Trigger points in quadratus lumborum

Assessment

1. Acute Lumbar Strain/Sprain (ICD-10: S39.012A)
   • Mechanical low back pain with muscle spasm
   • Left-sided facet joint dysfunction L4-L5
   • Postural dysfunction with lateral shift

Plan

1. Treatment Provided Today:

   • Diversified adjustment to L4-L5
   • Myofascial release to paraspinal muscles
   • Electrical muscle stimulation
   • Cryotherapy

2. Home Care Instructions:

   • Ice 20 minutes every 2-3 hours
   • Avoid prolonged sitting
   • McKenzie extension exercises
   • Proper lifting mechanics education

3. Treatment Schedule:

   • 3 visits per week for 2 weeks
   • Re-evaluation after 6 visits
   • Total 6-8 visits anticipated

4. Goals:

   • Reduce pain to 2/10 or less
   • Restore full ROM
   • Return to normal ADLs

CPT Codes:

• 98940 (Chiropractic manipulation)
• 97110 (Therapeutic exercises)
• 97014 (Electrical stimulation)

2. Cervical Spine Dysfunction

Description

The patient presents with chronic neck pain and stiffness related to poor posture and computer work, seeking chiropractic care for pain relief and posture correction.

SOAP Note

Patient Name: Sarah Johnson

Date of Visit: 09/02/2024

Subjective

Sarah Johnson, a 35-year-old female, presents with chronic neck pain and stiffness persisting for 6 months. Reports daily tension-type discomfort rated 5/10, worse at end of workday. Experiences frequent headaches originating from base of skull. Works as software developer, 8+ hours daily at computer. Reports temporary relief with stretching and massage. No radicular symptoms. Previous physical therapy 3 months ago with partial improvement.

Objective

• Vital Signs:
  • BP: 120/76 mmHg
  • HR: 72 bpm
  • RR: 14/min
• Postural Analysis:
  • Forward head posture
  • Rounded shoulders
  • Upper crossed syndrome
• Range of Motion (Cervical):
  • Flexion: 45° (normal)
  • Extension: 40° (limited)
  • Rotation: 60° bilateral (limited)
  • Lateral Flexion: 30° bilateral (limited)
• Orthopedic Tests:
  • (+) Cervical Compression
  • (+) Spurling's Test right side
  • (-) Upper Limb Tension Test
• Palpation:
  • Hypertonicity in upper trapezius
  • Restricted joint motion C5-C6
  • Tender suboccipital muscles

Assessment

1. Cervical Segmental Dysfunction (ICD-10: M99.01)
   • Postural strain syndrome
   • C5-C6 joint dysfunction
   • Myofascial pain syndrome

Plan

1. Treatment Provided Today:

   • Diversified adjustment to cervical spine
   • Soft tissue therapy to trapezius
   • Cervical traction
   • Postural exercises

2. Home Care Instructions:

   • Postural correction exercises
   • Workstation ergonomic modifications
   • Cervical stretches every 2 hours
   • Heat therapy at home

3. Treatment Schedule:

   • 2 visits per week for 4 weeks
   • Re-evaluation after 8 visits
   • Total 8-10 visits anticipated

4. Goals:

   • Improve cervical ROM
   • Reduce headache frequency
   • Correct postural abnormalities

CPT Codes:

• 98941 (Chiropractic manipulation)
• 97140 (Manual therapy)
• 97012 (Mechanical traction)

3. Sciatica

Description

The patient presents with right-sided sciatica symptoms, including low back pain radiating down the leg, seeking chiropractic care for pain relief and nerve decompression.

SOAP Note

Patient Name: Michael Torres

Date of Visit: 09/03/2024

Subjective

Michael Torres, a 38-year-old male, presents with right-sided low back pain radiating down posterior thigh to lateral calf. Symptoms began gradually 2 weeks ago, now rated 8/10. Reports numbness and tingling in right foot, worse with sitting and coughing. Pain decreases with walking and lying prone. Morning pain and stiffness lasting 1 hour. Job as truck driver requires prolonged sitting. No previous similar episodes. Taking naproxen with minimal relief.

Objective

• Vital Signs:
  • BP: 130/84 mmHg
  • HR: 78 bpm
  • RR: 16/min
• Postural Analysis:
  • Right pelvic tilt
  • Reduced right heel strike during gait
  • Antalgic posture
• Neurological:
  • Diminished right Achilles reflex
  • Decreased sensation L5 dermatome
  • Motor strength 4/5 right ankle dorsiflexion
• Orthopedic Tests:
  • (+) Straight Leg Raise right at 30°
  • (+) Seated Nerve Tension Test
  • (+) Crossed Straight Leg Raise
• Palpation:
  • Right piriformis tension
  • L5-S1 joint restriction
  • Paraspinal muscle guarding

Assessment

1. Sciatica with Lumbar Radiculopathy (ICD-10: M54.42)
   • Right L5-S1 nerve root compression
   • Piriformis syndrome
   • Lumbar facet dysfunction

Plan

1. Treatment Provided Today:

   • Cox flexion-distraction technique
   • Piriformis release therapy
   • Neural mobilization
   • Interferential current therapy

2. Home Care Instructions:

   • Neural flossing exercises
   • Prone press-ups
   • Sitting modifications
   • Ice/heat contrast therapy

3. Treatment Schedule:

   • 3 visits per week for 2 weeks
   • Re-evaluation after 6 visits
   • Total 8-12 visits anticipated

4. Goals:

   • Reduce radicular symptoms
   • Improve nerve function
   • Return to work activities

CPT Codes:

• 98941 (Chiropractic manipulation)
• 97110 (Therapeutic exercises)
• 97014 (Electrical stimulation)

4. Thoracic Spine Pain

Description

The patient presents with mid-back pain and rib cage discomfort, seeking chiropractic care for pain relief and improved mobility.

SOAP Note

Patient Name: Emily Parker

Date of Visit: 09/04/2024

Subjective

Emily Parker, a 29-year-old female, presents with mid-back pain between shoulder blades, present for 3 weeks. Reports sharp pain rated 6/10, worse with deep breathing and prolonged sitting. Works as accountant with long hours at desk. Notes clicking sensation with certain movements. No radiation of symptoms. Previous episode 1 year ago resolved with chiropractic care. Currently using heating pad for temporary relief.

Objective

• Vital Signs:
  • BP: 118/74 mmHg
  • HR: 70 bpm
  • RR: 16/min
• Postural Analysis:
  • Increased thoracic kyphosis
  • Forward head carriage
  • Bilateral rounded shoulders
• Range of Motion (Thoracic):
  • Flexion: Normal
  • Extension: Limited with pain
  • Rotation: 25° bilateral with pain
• Orthopedic Tests:
  • (+) Costotransverse Spring Test
  • (+) Seated Extension Test
  • (-) Thoracic Compression
• Palpation:
  • T4-T6 joint restriction
  • Tender rhomboid muscles
  • Costovertebral joint tenderness

Assessment

1. Thoracic Segmental Dysfunction (ICD-10: M99.02)
   • Costovertebral joint dysfunction
   • Postural strain
   • Myofascial pain syndrome

Plan

1. Treatment Provided Today:

   • Diversified adjustment to thoracic spine
   • Instrument-assisted soft tissue mobilization
   • Kinesiology taping
   • Postural exercises

2. Home Care Instructions:

   • Thoracic extension exercises
   • Foam roller techniques
   • Workstation modifications
   • Posture awareness training

3. Treatment Schedule:

   • 2 visits per week for 3 weeks
   • Re-evaluation after 6 visits
   • Total 6-8 visits anticipated

4. Goals:

   • Restore normal thoracic mobility
   • Improve posture
   • Reduce pain with breathing

CPT Codes:

• 98941 (Chiropractic manipulation)
• 97140 (Manual therapy)
• 97110 (Therapeutic exercises)

5. Whiplash Injury

Description

The patient presents with neck pain and associated symptoms following a motor vehicle accident, seeking chiropractic care for pain management and rehabilitation.

SOAP Note

Patient Name: Robert Chen

Date of Visit: 09/05/2024

Subjective

Robert Chen, a 45-year-old male, presents with neck pain and headaches following rear-end collision 5 days ago. Reports constant neck pain rated 7/10, worse with movement. Associated symptoms include dizziness, headaches, and upper back pain. Difficulty sleeping due to pain. No prior neck problems. Wearing soft collar since accident. ER visit post-accident cleared for serious injury. Currently taking prescribed muscle relaxants.

Objective

• Vital Signs:
  • BP: 132/86 mmHg
  • HR: 82 bpm
  • RR: 18/min
• Cervical ROM:
  • Flexion: 20° (limited)
  • Extension: 15° (limited)
  • Rotation: 30° bilateral (limited)
  • Lateral Flexion: 20° bilateral (limited)
• Orthopedic Tests:
  • (+) Cervical Compression
  • (+) Maximum Compression
  • (+) Jackson's Test
• Neurological:
  • Intact reflexes
  • Normal sensation
  • 5/5 muscle strength upper extremities

Assessment

1. Cervical Acceleration/Deceleration Injury (ICD-10: S13.4XXA)
   • Acute whiplash syndrome
   • Cervical muscle strain
   • Post-traumatic headache

Plan

1. Treatment Provided Today:

   • Gentle mobilization
   • Soft tissue therapy
   • Cold laser therapy
   • Cervical stabilization exercises

2. Home Care Instructions:

   • Ice therapy protocol
   • Gentle ROM exercises
   • Proper pillow positioning
   • Activity modification

3. Treatment Schedule:

   • 3 visits per week for 4 weeks
   • Re-evaluation after 6 visits
   • Total 12-15 visits anticipated

4. Goals:

   • Reduce acute pain and inflammation
   • Restore normal ROM
   • Prevent chronic symptoms

CPT Codes:

• 98940 (Chiropractic manipulation)
• 97140 (Manual therapy)
• 97110 (Therapeutic exercises)
• 97032 (Electrical stimulation)

6. Headaches

Description

The patient presents with chronic tension headaches and associated neck pain, seeking chiropractic care for pain relief and prevention.

SOAP Note

Patient Name: Amanda Foster

Date of Visit: 09/06/2024

Subjective

Amanda Foster, a 32-year-old female, presents with chronic tension headaches occurring 3-4 times weekly for past 6 months. Describes bilateral pressure-type pain rated 6/10, starting at base of skull and radiating to temples. Associated neck stiffness and shoulder tension. Headaches worse with stress and computer work. Currently taking OTC pain relievers 3-4 times weekly. Previous massage therapy provided temporary relief.

Objective

• Vital Signs:
  • BP: 122/78 mmHg
  • HR: 74 bpm
  • RR: 16/min
• Cervical ROM:
  • Full with end-range discomfort
  • Decreased rotation right
• Muscle Testing:
  • Deep neck flexors weak
  • Upper trapezius hypertonic
• Palpation:
  • Suboccipital muscle tension
  • C1-C2 joint restriction
  • Tender points in temporalis

Assessment

1. Cervicogenic Headache (ICD-10: M54.81)
   • Upper cervical dysfunction
   • Muscle tension headache
   • Postural component

Plan

1. Treatment Provided Today:

   • Upper cervical adjustment
   • Suboccipital release
   • Trigger point therapy
   • Deep neck flexor training

2. Home Care Instructions:

   • Self-massage techniques
   • Stress management
   • Ergonomic modifications
   • Neck strengthening exercises

3. Treatment Schedule:

   • 2 visits per week for 6 weeks
   • Re-evaluation after 8 visits
   • Total 12 visits anticipated

4. Goals:

   • Reduce headache frequency
   • Improve cervical function
   • Decrease medication usage

CPT Codes:

• 98940 (Chiropractic manipulation)
• 97140 (Manual therapy)
• 97110 (Therapeutic exercises)

7. Sacroiliac Joint Dysfunction

Description

The patient presents with sacroiliac joint pain and pelvic dysfunction, seeking chiropractic care for pain relief and stabilization.

SOAP Note

Patient Name: Rachel Thompson

Date of Visit: 09/07/2024

Subjective

Rachel Thompson, a 36-year-old female, presents with right-sided low back and buttock pain present for 4 weeks. Reports pain rated 5/10, worse with transitional movements and prolonged standing. Pain pattern inconsistent throughout day. Recently started running program. Previous history of pregnancy-related pelvic pain. Reports clicking sensation with certain movements. Currently using OTC anti-inflammatories as needed.

Objective

• Vital Signs:
  • BP: 118/76 mmHg
  • HR: 72 bpm
  • RR: 16/min
• Postural Analysis:
  • Right iliac crest elevated
  • Anterior pelvic tilt
  • Compensatory lumbar curve
• Orthopedic Tests:
  • (+) FABER Test right side
  • (+) Gaenslen's Test
  • (+) SI Joint Compression
• Palpation:
  • Right SI joint tenderness
  • Piriformis hypertonicity
  • Gluteal trigger points

Assessment

1. Sacroiliac Joint Dysfunction (ICD-10: M53.3)
   • Right SI joint hypomobility
   • Pelvic obliquity
   • Myofascial component

Plan

1. Treatment Provided Today:

   • SI joint manipulation
   • Pelvic blocking techniques
   • Soft tissue therapy
   • Core stabilization exercises

2. Home Care Instructions:

   • SI joint stabilization exercises
   • Proper lifting mechanics
   • Activity modification
   • Ice/heat protocol

3. Treatment Schedule:

   • 2 visits per week for 4 weeks
   • Re-evaluation after 6 visits
   • Total 8 visits anticipated

4. Goals:

   • Restore SI joint mobility
   • Improve pelvic stability
   • Return to running activities

CPT Codes:

• 98941 (Chiropractic manipulation)
• 97140 (Manual therapy)
• 97110 (Therapeutic exercises)

8. Shoulder Impingement

Description

The patient presents with right shoulder pain and limited range of motion consistent with impingement syndrome, seeking chiropractic care for pain relief and rehabilitation.

SOAP Note

Patient Name: Daniel Wilson

Date of Visit: 09/08/2024

Subjective

Daniel Wilson, a 45-year-old male, presents with right shoulder pain persisting for 6 weeks. Reports pain rated 6/10, worse with overhead activities and reaching behind back. Works as painter requiring frequent overhead work. Notes night pain when lying on affected side. Previous cortisone injection 2 months ago provided temporary relief. No recent trauma or injury.

Objective

• Vital Signs:
  • BP: 124/78 mmHg
  • HR: 76 bpm
  • RR: 16/min
• Shoulder ROM:
  • Abduction: 110° (painful arc 70-110°)
  • Flexion: 140° with pain
  • Internal Rotation: Limited
  • External Rotation: Normal
• Orthopedic Tests:
  • (+) Hawkins-Kennedy Test
  • (+) Neer's Test
  • (+) Empty Can Test
• Palpation:
  • Supraspinatus tenderness
  • Upper trapezius tension
  • AC joint tenderness

Assessment

1. Shoulder Impingement Syndrome (ICD-10: M75.41)
   • Rotator cuff tendinopathy
   • Scapular dyskinesis
   • Occupational overuse

Plan

1. Treatment Provided Today:

   • Shoulder manipulation
   • Graston technique
   • Kinesiology taping
   • Rotator cuff exercises

2. Home Care Instructions:

   • Pendulum exercises
   • Scapular stabilization
   • Work modification strategies
   • Ice therapy

3. Treatment Schedule:

   • 2 visits per week for 6 weeks
   • Re-evaluation after 8 visits
   • Total 12 visits anticipated

4. Goals:

   • Increase pain-free ROM
   • Improve rotator cuff strength
   • Return to work activities

CPT Codes:

• 98943 (Extremity manipulation)
• 97140 (Manual therapy)
• 97110 (Therapeutic exercises)

9. Plantar Fasciitis

Description

The patient presents with chronic heel pain consistent with plantar fasciitis, seeking chiropractic care for pain management and foot mechanics improvement.

SOAP Note

Patient Name: Jennifer Martinez

Date of Visit: 09/09/2024

Subjective

Jennifer Martinez, a 41-year-old female, presents with left heel pain present for 3 months. Reports severe morning pain rated 8/10, improving slightly with activity but worse by end of day. Works as retail manager requiring prolonged standing. Recently increased walking exercise. Previous history of similar symptoms 2 years ago. Currently using OTC arch supports with minimal relief.

Objective

• Vital Signs:
  • BP: 122/76 mmHg
  • HR: 70 bpm
  • RR: 16/min
• Foot Examination:
  • Pes planus left foot
  • Heel valgus deformity
  • Limited toe extension
• Orthopedic Tests:
  • (+) Windlass Test
  • (+) Plantar Fascia Tension Test
  • (+) Heel Squeeze Test
• Palpation:
  • Plantar fascia thickening
  • Calcaneal tenderness
  • Gastrocnemius tension

Assessment

1. Plantar Fasciitis (ICD-10: M72.2)
   • Chronic plantar fascia strain
   • Biomechanical dysfunction
   • Occupational aggravation

Plan

1. Treatment Provided Today:

   • Foot manipulation
   • Soft tissue mobilization
   • Ultrasound therapy
   • Taping technique

2. Home Care Instructions:

   • Plantar fascia stretches
   • Ice bottle rolling
   • Proper footwear education
   • Activity modification

3. Treatment Schedule:

   • 2 visits per week for 4 weeks
   • Re-evaluation after 6 visits
   • Total 8 visits anticipated

4. Goals:

   • Reduce morning pain
   • Improve foot mechanics
   • Return to normal activities

CPT Codes:

• 98943 (Extremity manipulation)
• 97035 (Ultrasound)
• 97110 (Therapeutic exercises)

10. TMJ Disorders

Description

The patient presents with temporomandibular joint dysfunction and associated symptoms, seeking chiropractic care for pain relief and jaw function improvement.

SOAP Note

Patient Name: Laura Bennett

Date of Visit: 09/10/2024

Subjective

Laura Bennett, a 28-year-old female, presents with bilateral jaw pain and clicking present for 2 months. Reports pain rated 5/10, worse with chewing and yawning. Notes morning jaw stiffness and occasional headaches. History of teeth grinding at night. Reports increased stress at work. Previous night guard provided some relief. No recent dental work or trauma.

Objective

• Vital Signs:
  • BP: 120/74 mmHg
  • HR: 72 bpm
  • RR: 16/min
• TMJ Examination:
  • Clicking on opening right side
  • Deviation to right on opening
  • Limited opening (35mm)
• Muscle Testing:
  • Tender masseter muscles
  • Temporal muscle tension
  • SCM hypertonicity
• Palpation:
  • TMJ capsule tenderness
  • Pterygoid muscle tension
  • Cervical joint restrictions

Assessment

1. TMJ Dysfunction (ICD-10: M26.62)
   • Myofascial pain syndrome
   • Joint hypomobility
   • Stress-related bruxism

Plan

1. Treatment Provided Today:

   • TMJ mobilization
   • Intraoral massage
   • Cervical adjustment
   • Trigger point therapy

2. Home Care Instructions:

   • TMJ exercises
   • Stress management
   • Dietary modifications
   • Sleep position education

3. Treatment Schedule:

   • 2 visits per week for 4 weeks
   • Re-evaluation after 6 visits
   • Total 8 visits anticipated

4. Goals:

   • Improve jaw ROM
   • Reduce muscle tension
   • Decrease clicking

CPT Codes:

• 98940 (Chiropractic manipulation)
• 97140 (Manual therapy)
• 97124 (Massage therapy)

[Continue with remaining examples following same pattern...]