SOAP Charting System • v4.4.72 ⏳ Connecting...
Patient Information
📋
Initial Eval
🔄
Follow-up
Cause of Injury
Treating Therapist
Payer Type
Select payer for compliance guidance
🏗️ WC
🏥 PH
🏛️ MC
💵 OOP
Workers' Compensation: 97010 (hot/cold packs) has no billing value for WC claims.
Session Duration (8-Minute Rule)
Select based on physician referral body zones
Single Body Zone
30 min
Dual Body Zone
60 min
S - Subjective
Dictate Subjective
0:00 / 5:00
💡 Prompt: Describe what the patient reports — pain levels, symptoms, what makes it better or worse, how they've been since last visit...
📝 Transcript
Pain Levels (0-10)
Tension Levels (0-10)
Resting muscle tension separate from pain
Pain History Since Last Visit
Symptom Locations
As per diagnosis or condition
Specific Symptoms
Click a symptom to add severity & frequency details
With Radiating Pain To
Aggravating Factors
Relieving Factors
Additional Patient Statements
Activities, observations, and other patient-reported information
Additional Notes
O - Objective
Dictate Objective
0:00 / 5:00
💡 Prompt: Describe what you observed and found — visual observations, ROM, palpation findings, muscle tone, gait, posture, tissue quality...
📝 Transcript
Visual Observations
Gait
Posture
Restricted Movement
Swelling
Range of Motion Testing (Intake)
Restricted ROM (quick select)
Palpatory Examination
A - Assessment
Dictate Assessment
0:00 / 5:00
💡 Prompt: Describe your clinical impression — patient's response to treatment, progress toward goals, changes in condition, outcomes observed...
📝 Transcript
Diagnosis (ICD-10)
Post-Treatment Pain
Post-Treatment Tension
Compare post-treatment muscle tension to intake levels
Post-Treatment ROM Assessment
Compare post-treatment ROM to intake measurements
Functional Outcomes
Clinical Opinion
P - Plan
Dictate Plan
0:00 / 5:00
💡 Prompt: Describe the treatment plan — procedures performed, home exercises, frequency recommendations, next appointment, goals...
📝 Transcript
Evaluation Type
Select the appropriate evaluation complexity level
Treatment Procedures (CPT) with Time
Select procedures and assign time per 8-minute rule
Total Treatment Time
15 min
Regions Treated
Treatment Goals
Treatment Objectives
Exercises and/or Stretches Demonstrated
Treatment Plan
Follow-Up Recommendations
☐Patient referred back to physician
Review & Print
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Summary
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