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MyEMR® 2008 for Windows XP and Windows Vista

MyEMR for Windows is chiropractic SOAP note documentation software for chiropractors that includes random text generation for dictation quality SOAP notes and reports.

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Subjective Complaints

The subjective complaint portion of a chiropractic SOAP note provides a brief description regarding the status of the complaints from the patient's perspective.  Typical subjective complaint content includes:

  1. Overall status of the complaint, indicating improvement or exacerbation of symptoms.
  2. Recurrence or exacerbation of pre-existing complaint symptoms.
  3. History of occurrence, including diagnostic testing, surgery, or recommendations for diagnostic testing or surgery.
  4. Changes in diet, exercise, activities of daily living and changes in OTC medication, prescription medication and dietary supplements.
 Objective Findings

The objective findings portion of a chiropractic SOAP note involves findings and conclusions as determined by the treating physician.  The objective findings generally have a correlation with the patient subjective complaints, but not in all cases.  The patient may have paresthetic pain that the patient may not realize a connection to the objective findings of the genuine source of the complaints, or a patient on disability may be exaggerating the extent of their complaints.

The general form of objective findings involve:

  1. Looking at the patient – The visual observations including walk, gait, postural analysis, grooming, mental state, etc.
  2. Touching the patient – static and motion palpation of the spine and/or extremities of the skeletal structure, and the musculature that supports the skeletal structure, including muscle spasm, hyper-tonicity, hypo-tonicity, pain, edema, temperature differential.
  3. Testing the patient – exams that are collections of orthopedic tests, neurological (deep tendon response) reflexes, neurological signs, muscle tests, sensory tests and range of motion testing.  Testing may also include vital signs and reexamination.

Initial visits and re-examination visits, or visits that involve significance of exacerbation, recurrence of injury or new injuries should involve more detail than routine follow up visits.  This should include a more detailed subjective onset history from the patient as well as inclusion of appropriate diagnostic testing and the diagnostic impression of the additional studies.

Assessment

The assessment portion of a chiropractic SOAP note describes a summary of the current diagnosis and status of the patient's condition.  This includes:

  1. Diagnostic impression.
  2. Changes in the diagnosis.
  3. The improvement or regression of the subjective complaints.
  4. Total and/or partial disability dates.
 Plan

The treatment plan portion of a chiropractic SOAP note should indicate the short to long term goals of treatment.  This typically includes:

  1. The initial treatment plan, including the visit frequency (or next appointment) and treatment modalities.
  2. The treatment plan involved for each date of service.
  3. Patient response to treatment.
  4. Home exercise or therapy recommendations.
  5. Therapeutic equipment sold or issued to the patient, such as ice or cold packs, pillows, canes, crutches, etc.

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