SOAP

The clinical record. Five screens, following the SOAP structure:

Screen	Records
Subjective	What the patient reports — complaints, severity, what makes it worse or better
Objective	What you find — spinal listings, fixation, tonicity, pain and edema
Assessment	Your conclusion — condition status, progress, diagnosis, prognosis
Treatment Plan	What you will do — modalities, frequency, phase of care
Pain Scale	The patient's own rating of severity and frequency

Entries from these screens generate the SOAP note itself, which is produced from Generate and stored under Document.

What Medicare expects in every note

The documented minimum

Every SOAP note must include:

• Patient comments and complaint history — from Subjective
• The physical findings for that visit — from Objective
• The condition status — from Assessment
• The current active diagnosis — from the Diagnosis tab
• The treatment plan

Miss any of these and the note may not support the claim built on it.

Why notes are worded differently each time

ChiroPad generates note text from libraries of alternative phrasings, picked at random and weighted, so consecutive visits don't read identically.

That's a compliance feature, not a flourish

State board and federal rules require each visit's note to be genuinely its own. A run of notes that are word-for-word identical is what an auditor reads as cloned documentation — and it undermines every claim built on them.

The corollary: enter what the patient actually said and what you actually found, each visit. The randomiser varies the wording; it cannot vary the substance.

Nothing is forced

ChiroPad does not require you to complete fields before saving. The provider records what they judge appropriate.

The consequence of that freedom

Because nothing blocks you, compliance gaps are silent. The fields that regulators actually require — laterality, complaint history, condition status, plan phase — can all be left blank and the note will still generate. Those are flagged individually on the screens that own them.

Controlling what goes into a note

Each section of a note can be forced in or suppressed out at generation time.

Neither extreme is safe

Suppress All produces a note that no longer meets Medicare's minimum, or many state boards'.

Force All goes the other way, padding the note with material that was not recorded on that visit — which is its own audit problem.

Set them deliberately, section by section.

Editing a note afterwards

Changes after 72 hours must be addenda

Medicare requires a note to be completed within 72 hours of the visit. Anything changed after that must be entered as an addendum, never as a silent edit — every entry is timestamped in the audit log, and auditors know where to look.

See Document for how addenda work.

Signing

Notes are signed electronically from the provider's record.

Initials alone are no longer enough

Medicare and state boards require the provider's full name and credentials on each note.