Mastering Routine Chiropractic Office Visits: Documentation That Payers Want to See

Routine Chiropractic Office Visits: How to Document SOAP Notes Correctly

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Routine chiropractic office visits are an essential part of patient care. However, many providers struggle to understand how much detail these visits require, or how they differ from an initial evaluation. To improve clarity and consistency, Dr. Erin Stubblefield from the KMC University HelpDesk explains how to document routine chiropractic office visits using a simple, compliant approach.

Let’s walk through how these visits work within the chiropractic episode of care model and what you should include in your SOAP notes to keep your documentation clean, efficient, and payer-friendly.

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Initial Visits vs. Routine Visits: Know the Difference

Every episode of care begins with an initial visit. This may occur when you see a brand-new patient or when an established patient presents with a new condition. During this visit, you perform an evaluation and management service, establish diagnoses, and create a treatment plan with functional goals.

After that first encounter, the patient enters routine chiropractic office visits. These visits focus on delivering the treatment plan—not recreating the initial evaluation. Because of this, your documentation should be shorter, more targeted, and specific to the patient’s functional progress.

The Purpose of Routine Chiropractic Office Visits

Routine visits allow you to implement the treatment plan and track the patient’s response to care. Although they require less documentation than an initial visit, you must still capture the information needed to justify continued care. This is where SOAP notes become essential.

S – Subjective: Focus on Functional Change

During routine chiropractic office visits, the patient’s subjective report should highlight changes since the last visit. Pain levels matter, but payers primarily want to see:

• Functional improvement
• Functional decline
• The patient’s ability to perform daily activities

Because functional goals were set during the initial visit, each routine note should connect patient feedback to those goals.

O – Objective: Measure What You See

Your objective findings validate the patient’s report. Observable and measurable data show why treatment is still appropriate. Many chiropractors rely on the PART protocol (Pain, Asymmetry, Range of Motion, Tissue Tone) because it keeps the objective section efficient and consistent.

• Objective findings may include:
• Segmental restrictions
• Soft tissue changes
• Neurological or orthopedic findings related to the plan of care

A – Assessment: Bring Subjective and Objective Together

The assessment is your professional interpretation. With transition words like “therefore,” “however,” and “because,” this section explains why the patient needs continued care.

Examples include:

• “The patient continues to progress toward goals.”
• “However, symptoms increased after an exacerbation.”
• “Therefore, additional visits remain medically appropriate.”

A few clear sentences are often all you need.

P – Plan: Document What You Performed

The plan section records:

• Areas adjusted
• Modalities or procedures provided
• Any updates to the treatment plan

Detail matters here for accuracy, billing, and compliance.

Why Strong Routine Visit Documentation Matters

Although routine chiropractic office visits require less detail than an initial evaluation, high-quality SOAP notes strengthen:

• Medical necessity
• Claim defensibility
• Payer communication
• Clinical continuity
• Team consistency

When your documentation matches the patient’s functional goals and progress, you stay compliant without adding unnecessary steps.

KMC University regularly helps chiropractic practices like yours refine documentation through a Proactive Chart Review. If you are unsure or would like support,  Schedule a Free Discovery Assessment! Our specialists are ready to guide you.

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Dr. Erin Stubblefield graduated from Palmer College of Chiropractic in Davenport, IA in 2006. After practicing privately, she transitioned to Chiropractic education for 13 years before joining KMC University as a Specialist in 2024. Currently, Dr. Stubblefield is the owner of Sunflower Consulting, LLC, a healthcare consulting and practice coaching group. Dr. Stubblefield partners with KMC to provide accurate, current, and compliant information. For further information, you can reach her at drerin@kmcuniversity.com.