How do these notes support insurance billing?

Payers look for medical necessity: a documented complaint, objective findings, an assessment with appropriate diagnosis codes, and a plan showing the care is active and producing (or reasonably expected to produce) improvement. Specific, dated notes that track progress are what justify continued visits.

Are these notes confidential?

Yes — chiropractic records are protected health information under HIPAA, plus state record-content and retention rules. Store them securely, limit access, and follow your state board's documentation and retention requirements.

How do these notes support insurance billing?

Payers look for medical necessity: a documented complaint, objective findings, an assessment with appropriate diagnosis codes, and a plan showing the care is active and producing (or reasonably expected to produce) improvement. Specific, dated notes that track progress are what justify continued visits.

Are these notes confidential?

Yes — chiropractic records are protected health information under HIPAA, plus state record-content and retention rules. Store them securely, limit access, and follow your state board's documentation and retention requirements.

Chiropractic Adjustment Notes

A per-visit chiropractic SOAP note — patient and DC, Subjective / Objective (posture, ROM, palpation, ortho/neuro), Assessment (segments/subluxations, diagnosis), and Plan (levels adjusted, technique, modalities, home-care, frequency), with signature.

Customise

Clinic name

Chiropractor (DC)

Patient name

Date

Visit #

S — Subjective (complaint, pain)

O — Objective (exam findings)

Segments / subluxations

A — Assessment / diagnosis

Adjustment technique

Adjustments performed (levels)

Modalities / therapies

P — Plan (home-care & frequency)

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Align Chiropractic
CHIROPRACTIC ADJUSTMENT NOTES

Chiropractor: Dr. Lee Nguyen, DC
Patient: Alex Morgan     Date: June 19, 2026     Visit #: 6

S — SUBJECTIVE
Low-back pain 4/10 (was 7/10 at visit 1), R-sided, worse with prolonged sitting; neck tension improving. No new radicular symptoms, no bowel/bladder changes.

O — OBJECTIVE (exam)
Posture: mild R pelvic obliquity. ROM: lumbar flexion improved, mild end-range extension discomfort. Palpation: hypertonic R lumbar paraspinals, restricted/tender L4-L5, R SI. Ortho: Kemp's mild R+; SLR negative. Neuro: DTRs 2+ symmetric, sensation intact.
   Segments / subluxations: L4-L5 (restricted, R rotation), R sacroiliac, C2 (R), T6.

A — ASSESSMENT / DIAGNOSIS
Lumbar segmental dysfunction with R SI joint involvement and mild myofascial component; improving with care (M99.03 / M54.5). Cervical dysfunction, stable.

P — PLAN
   Technique: Diversified
   Adjustments performed: L4-L5 P-A (diversified), R SI side-posture, C2 toggle, T6 P-A. Patient tolerated well, audible release noted.
   Modalities: Pre-adjustment: e-stim 10 min + moist heat to lumbar; post: soft-tissue to R paraspinals.
   Home-care & frequency: Continue 2x/week for 2 weeks, then re-evaluate and taper. Home-care: McKenzie extensions 2x/day, walking, ergonomic sitting + hourly breaks, ice if flare. Re-exam at visit 8.

(Informed consent for chiropractic care on file. This note documents one visit
and is not a substitute for evaluation of red-flag or emergent findings.)

Chiropractor signature: ____________________________   Date: ______________
                        Dr. Lee Nguyen, DC

About this template

Chiropractic adjustment notes are SOAP notes with a chiropractic spine: alongside the standard structure they document **which segments were assessed and adjusted, with what technique** — the detail that makes care reproducible and supports medical-necessity billing. **Subjective** is the patient's report: complaint, pain rating and how it has changed, aggravating factors, and — important for safety — the absence (or presence) of red flags like new radicular symptoms or bowel/bladder changes. **Objective** is the exam: posture, range of motion, static and motion palpation findings, and relevant orthopedic/neurologic tests. **Assessment** lists the segmental dysfunctions/subluxations and the working diagnosis (often with ICD codes), plus the trajectory (improving, plateaued). **Plan** is the heart for a chiropractor: the **levels adjusted and the technique** (Diversified, Gonstead, Activator, Thompson drop), any **modalities** (e-stim, heat, soft-tissue), home-care, and the **visit frequency with a re-evaluation point**. Two professional notes: **informed consent** for chiropractic care — including a discussion of the small risks, especially with cervical manipulation — is the standard of care and required in many states, so reference it; and the note is **documentation, not a substitute for recognizing red flags** that warrant referral or imaging. Keep records HIPAA-secure, document each visit against the plan, and write enough specificity (levels, technique, response) to justify continued care.

When to use it

Charting a chiropractic visit in SOAP format.
Documenting segments adjusted and the technique used.
Tracking progress and medical necessity for billing.
Setting visit frequency and a re-evaluation point.

What to include

Patient, chiropractor, date, and visit number.
Subjective (complaint, pain, red-flag screen).
Objective (posture, ROM, palpation, ortho/neuro) and segments.
Assessment (subluxations, diagnosis/codes, trajectory).
Plan: levels adjusted, technique, modalities, home-care, frequency, signature.

Frequently asked

The specificity in Objective and Plan: documenting the segmental/subluxation findings, exactly which levels were adjusted, and the technique used (Diversified, Gonstead, Activator, Thompson). That detail supports continuity of care and medical-necessity documentation for insurance.

⚠ Legal disclaimer. These chiropractic adjustment notes are a general SOAP documentation template, not legal or medical advice. Chiropractic is state-licensed with a defined scope; informed consent (including risks of cervical manipulation) is the standard of care and often legally required, and a visit note is documentation that does not replace recognizing red-flag findings that warrant referral or imaging. Records are protected health information under HIPAA and state rules — store securely. Adapt to your jurisdiction and document medical necessity for any billing.

Jurisdiction: United States — a clinical SOAP/visit note for a licensed Doctor of Chiropractic (DC). Chiropractic is state-licensed with a defined scope; informed consent (including discussion of risks such as, rarely, cervical artery events with neck manipulation) is the standard of care and required in many states. Records are protected health information (HIPAA) and subject to state record-content/retention rules; documentation must support any insurance billing (medical necessity).

Last reviewed: 2026-05

Reviewed by ScoutMyTool — consult a licensed attorney for binding use.