Chiropractic Soap Note

SOAP Note

The following document has been prepared by Patricia D. Adams, a medical professional at Quantum Leap Innovations. This is a standardized SOAP (Subjective, Objective, Assessment, Plan) note for intended use by chiropractic practitioners. Utilizing this SOAP note helps ensure the provision of thorough yet concise patient evaluations, whilst maintaining an optimally formatted and professional presentation.

Abbreviation

Description

Subjective

  • Patient: Daniel Taylor

  • Age: 38 years

  • Sex: Male

  • Height: 6'2"

  • Weight: 200 lbs

  • Health History: Non-smoker, moderate physical activity, no known heart conditions

Objective

  • Body Posture: Poor, indicating potential musculoskeletal issues

  • Pain and Discomfort: Reports recurrent lower back pain

  • Mobility: Displays limited range of motion due to discomfort

  • Vital signs: Within normal ranges

Assessment

The patient's recurrent lower back pain combined with mobility limitations suggest the possibility of a lumbar musculoskeletal disorder. Further diagnostic evaluations are advised to confirm this preliminary assessment.

Plan

  • Diagnostic Tests: Order radiographic imaging to evaluate lumbar spine structure

  • Interventions: Recommend chiropractic adjustments and physiotherapy if diagnosis confirmed

  • Follow-up: Schedule for two weeks from now to assess the outcome of interventions

Date of completion: 21st February, 2050.

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