Tips on Subjective vs. Objective

Tips on Subjective vs Objective

In the current climate of personal injury and insurance claims, Chiropractors know that keeping detailed records of their patient's care is crucial for providing high-quality treatment and ensuring positive health outcomes. That's why many chiropractors have turned to ChiroSOAP, a specialized form of SOAP notes designed specifically for chiropractic care.

With ChiroSOAP, chiropractors can streamline their documentation process while ensuring that their SOAP notes are thorough, accurate, compliant, and effective. ChiroSOAP consists of two info-gathering sections: the subjective and objective sections.

In the subjective section, chiropractors can record their patients' chief complaints and medical history. However, ChiroSOAP emphasizes the importance of keeping this section concise and focused on the patient's primary concerns. This helps to avoid confusion and time-consuming documentation, allowing chiropractors to spend more time providing effective treatment.

In the objective section, ChiroSOAP encourages chiropractors to provide detailed and specific information, including specialized tests and imaging studies. This helps to ensure that the diagnosis is accurate and that the treatment plan is appropriate for the patient's condition. By including this information, chiropractors can develop treatment plans that are customized to each patient's needs and provide the best possible care.

At ChiroSOAP, we emphasize the verification of objective findings. ChiroSOAP recognizes that objective measures are critical for supporting the diagnosis and treatment plan in chiropractic care. However, it also emphasizes the need for verification through specialized tests and imaging. By verifying these findings, chiropractors can ensure that their diagnoses are accurate and that their treatment plans are effective.

Providing detailed descriptions of a patient's symptoms may seem like a good idea, but it can actually be confusing and time-consuming, especially when you are running a busy practice where you don’t have the time to spend hours working on notes… after all, It’s getting people better than we like to focus on, correct? Instead, it's much more efficient to use a concise description that captures the essence of the patient's complaint. For example, instead of saying "the patient complains of radiating numbness in the left ring and little fingers as well as the medial side of the left hand and forearm," you ould say "the patient reports numbness in the left upper extremity."

It's important to keep in mind that the lay public, including claims adjusters and jurors, may not understand the ramifications of symptom details. Instead, they may find it more useful to have objective measures, such as imaging studies, that provide a clear and concise explanation of the patient's condition. For example, stating that "MRI reveals disc protrusion on the left with compression of the left C7 nerve root" followed by an explanation of how this condition may lead to partial paralysis or require surgery, provides a clear and concise explanation of the patient's condition that is easy for others to understand.

In summary, while it's important to gather a patient's subjective complaints, it's crucial to ensure that this information is clear, concise, and focused on the patient's primary concern. In addition, using objective measures, especially imaging studies, can help others understand the patient's condition and the implications of the diagnosis.