Report Master Daily SOAP Note Sample
Below is a sample Daily SOAP Note generated by Report Master (fictitious, of course) showing the detail and quality of a Note written by the Report Master Software from start to finish. The Note took less than a minute to input all the data, and seconds to print. Shouldn't your practice be using Report Master?
(SPECIAL NOTE: This is an unedited Daily SOAP Note. In other words, this is how it looked after it was generated by the Report Master Program, without any additional editing.)
Backmender Family Chiropractic
1234 Wholesome Lane, Suite 3
Anytown, FL 34698
Attn: Mr. James Smith
Re: Mr. Alvin Aarbag - Visit Date: Sunday, August 24, 2014
On August 24, 2014, the above named patient presented himself for treatment of his
complaints stemming from a work related injury that he was involved in.
SUBJECTIVE COMPLAINTS:
Mr. Aarbag's current signs and symptoms were assessed today. His bilateral temporal
headache complaint has improved quite a bit since we last saw him. It was 3 on the
1 to 10 Pain Scale. It bothers the patient between 51% and 75% of the time he is awake.
His daily activities are seriously affected by this symptom. Usually getting worse in the
afternoon, it changes throughout the day. He stated that his low back pain has somewhat
worsened. On the 1 to 10 scale today, this complaint was rated at 5. It's experienced
between 25% and 50% of the time he is awake. This symptom is having some affect on
his daily activities. The evening usually finds it worse. His shoulder pain has experienced
slight improvement. On the 1 to 10 scale, it was 1. It bothers him less than 25% of the
time he is awake. His daily activities are presently unaffected by this symptom. The
evening usually finds it worse.
OBJECTIVE EVALUATION:
Range of Motion Studies:
Active and passive ranges of motion of the lumbar region of the spine were within normal
limits. Active and passive ranges of motion of the thoracic region of the spine were found
to be mildly restricted, with pain. Active and passive ranges of motion of the lumbar
region of the spine were moderately restricted, with pain and spasm.
Palpation Evaluation: Paraspinal Studies: Palpation of Mr. Aarbag's cervical, thoracic
and lumbar spinal regions revealed multiple fixations, hypertonicity, mild biomechanical
alterations (subluxations), tenderness, malalignments and trigger points.
ASSESSMENT/DIAGNOSIS/CURRENT TREATMENT:
Today's Assessment/Diagnosis: Mr. Aarbag is presently receiving medically necessary
therapeutic care, as he has not yet reached MMI. Since his last visit, the patient has
experienced some improvement.
ICD Codes:
307.81 Tension headache
350.1 Trigeminal Neuralgia
716.9 Inflamation Shoulder
719.0 Cervical Facet Joint Swelling
Prognosis: At this time, Mr. Aarbag's prognosis is good. His case is somewhat
complicated, but continued improvement is expected, despite permanent residuals
being a possibility.
Today's Modalities & Procedures: Following were the modalities used today:
chiropractic adjustment, Hubbard tank (97036), massage therapy (97124) for 60 minutes,
therapeutic procedures (97110) for 30 minutes, and work hardening (97546) for 1 hour,
along with whirlpool treatment. Cervical region treatment consisted of hot packs (97010),
massage therapy (97124) for 15 minutes, and mechanical traction (97012). The above was
for the purpose of decreasing pain, returning the patient to his preclinical status, retarding
degeneration and relieving symptoms of exacerbation.
FUTURE CARE PLAN:
Present Care Phase: As of today's visit, Mr. Aarbag is in a therapeutic and rehabilitative
phase of care.
Future Treatment Plan: My recommendation for future treatment consists of moist
heat therapy, lumbar traction, spinal manipulation and chiropractic adjustments two times
a week for seven weeks.
Goals of Treatment Plan: The preceding treatment plan has the goal of decreasing
pain, decreasing spasms, increasing strength, stabilizing segments, increasing flexibility
and relieving symptoms of exacerbation.
Sincerely,
Dr. James C. Brown, D.C.
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