SOAP Note Template (Chiropractic)
Published: 10/22/2025
About this template:
This chiropractic SOAP note template helps document patient evaluations and treatment sessions effectively. It provides structure for recording orthopedic and neurological findings, adjustment techniques, therapeutic modalities, and functional outcomes. The template supports comprehensive documentation of spine and extremity care, making it ideal for both initial evaluations and ongoing treatment monitoring.
Preview template
Subjective: 38-year-old male construction worker presents for third visit for acute lower back pain following lifting incident 2 weeks ago. Reports 50% improvement in pain intensity since initial visit. Pain now 4/10 (down from 8/10), localized to lower lumbar region without radiation. Able to return to light-duty work. Morning stiffness decreased from 45 minutes to 15 minutes. Compliance with home exercise program good. No numbness, tingling, or weakness in lower extremities.
Objective: Posture shows improvement with decreased left lateral listing. Active range of motion: Flexion 70% (improved from 50%), extension 60% (improved from 40%), lateral flexion and rotation bilaterally within functional limits. Palpation reveals decreased muscle spasm and tenderness over L4-L5 and L5-S1. Positive for mild tenderness over right sacroiliac joint. Orthopedic testing: Straight leg raise negative bilaterally, Patrick's test mildly positive on right. Gait normal.
Assessment and Plan:
- Acute lumbar facet syndrome with sacroiliac joint dysfunction, improving
- Treatment provided today: High-velocity low-amplitude adjustment to L4, L5, and right SI joint; soft tissue therapy to lumbar paraspinals; therapeutic exercises performed in office
- Progress good toward functional goals
- Continue home exercise program emphasizing core stabilization and stretching
- May advance to full duty work with proper body mechanics
Patient Education:
- Reinforced proper lifting techniques and body mechanics for work activities
- Demonstrated additional core strengthening exercises to add to home program
- Advised on importance of activity modification during healing phase
- Discussed ergonomic considerations for preventing future episodes
Next visit scheduled in one week, anticipate discharge to home program in 2-3 visits if continued improvement. Patient encouraged to contact office if symptoms worsen.
