Treatment Notes for Provider - Complete Guide

ChiroSpring gives you powerful options for provider documentation:

1. Use built-in Treatment Templates (recommended for most clinics)
2. Build your own Custom SOAP Note Template

You have many tools you can use within your Treatment Note Templates, they are fully customizable:

• Touch Screen Friendly
• Full Library of Macro Buttons
• You can free type and/or Dictate directly into any text box in template
• ChiroSpring Advanced Spine
• ChiroSpring Ai - Transcription, Rewrite and Chart Summary

It also includes:

• The Super Note (one template for nearly every visit)
• Save & Sign tracking for compliance
• Template activation and ordering controls

Supporting Videos:

Watch Training Video

Watch Training Video - Second Version

SETTINGS - TREATMENT NOTES - NOTES & FEE SLIP (Notes Settings Tab)

Ditto Options

• Set at the top, how you want your Treatment Note Template to copy forward (ie. SALT/DITTO)

You have options here as well for:

• Fee Slip Ditto
• Procedures Default View (on Fee Slip)
• Diagnosis Default View (icd on Fee Slip)
• Template Usage (Choose Use New Fee Slip template)
  • Choose option to ALLOW
    • Show option to create fee slip before treatment note
    • Hide option to create fee slip before treatment note

• Save & Sign Treatment Notes
  • Check: Allow providers to save notes and sign notes as two seperate steps

             RECOMMENDED

CLICK SAVE

Authorize Users to Sign Notes:

ChiroSpring includes 50+ prebuilt templates designed for:

• Speed
• Compliance
• Efficiency
• Various clinic types (cash, PI, integrative, PT, chiropractic, etc.)

How to Activate & Organize Templates

1. Go to Settings

   Select Treatment Notes - Notes & Fee Slip

   Browse templates by category:

   • Chiropractic
   • Physical Therapy
   • Personal Injury
   • Medical

   • General

     Click any template name to preview it

     Activate templates for:

   • Visible in Patient App- Completed, Signed Notes will now appear in the Patient Mobile App, you can uncheck here if you don't want those to auto populate in patient mobile app
   • Active On Patient Dashboard - That is your list from the Patient Treatment Dashboard to the Left AND when you drop down the note templates from the Front Desk - Checked In Column
   • Active On EHr - Is in the upper bar of screen that stays stagnant, when you are in a patient file, that icon will appear and can choose template activated and Start a New Note when selected
   • Active On Mobile - Is referencing the Provider Mobile App

WE RECOMMEND ONE TEMPLATE IN MOST CASES SO NO MATTER WHERE YOU OPEN YOUR TEMPLATE, YOU WILL SEE YOUR DITTO

You can also set the order they appear and Click Save

In the below image you will see "Active on Patient Dashboard" to the left and "Active on EHr Menu" in the upper, right drop down list

If you want complete control over layout, structure, and formatting, you can build your own.

This lets you design your note exactly how you want it using rows, columns, and controls.

How to Start

1. Go to Settings

2. Select Custom Templates

   Click Build Templates

   Choose form type: Treatment Note

3. Give the template a name - This will be a header at the top of your completed note
4. Choose category - Chiropractic, Physical Therapy, Personal Injury, Medical, General
5. Set Treatment Note Order (controls display order)

• Choose your starting point:

• New Template - Start from Scratch
• SOAP Template - Only gives SOAP sections
• Predefined Template
• Clinic Archive

The final step is to Build. The template builder has a list of programmed options that will assist you in creating a variety of inputs to your form including:

• Textbox (Label with text input)
• Number Input
• Memo field (Label with text, emoji, and image inputs allowed)
• Checkbox (Label with check box and sublevel checkbox/label)

  • Pro Tip on Checkboxes, make labels fully descriptive. Instead of:

    • Shoulder
      • Right
      • Left
    • Use:
      • Shoulder pain right side
      • Shoulder pain left side
  • It reads better in final output and improves compliance.
• Radio Group - This option allows for only ONE selection when documenting your note.  If you desire multiple selections use the check-box option instead.
  • Examples: Left, Right, Bilateral or Yes, No
• Labels (Put label text anywhere)
  • I like to use with Radio Group and Checkboxes, the Label is my question and radio group output
• Paragraph (descriptive content for note template)
  • You can Control+V or Paste Images into the Paragraph Box
  • Maybe you want your logo at the bottom
• Date picker - Will Include a Label, could use for Accident Date, Last Exam Date
• Time picker - Gives you option in your note template to choose a time
• Adjustment strip - The Label and selections are all that will appear on note output
  • Example: Manually palpated the patient at, Subluxation levels noted at

• Signature box (area for touchscreen signature for patient or provider)
• Body shape (with symptom icons for placement) 

• Dropdown (Label with picklist of drop-down items to choose an individual selection
• Percentage slider (Label with horizontal slide bar for indicating 0-100%)

• Meridians 

• Macros - This option utilizes the SOAP Macros within the software.  We have a separate article covering how to create, edit or arrange your SOAP Macros.  Once you have Macros created you can add them to your SOAP Template. 

• Table - This option allows you to arrange content into a grid.  Add as many rows or columns as you want.  Then individually add controls to each of these areas.  

• Basic Spine
• Advanced Spine
• Advanced Spine Findings - Follow the advanced spine article to note where to place your findings, usually under Objective
• Ai Scribe

You control spacing and structure with:

Columns

• More columns = narrower input fields
• Fewer columns = wider, longer note

Add Template Section

Creates new titled sections with independent columns.

Move Column

Drag and drop sections to reposition them.

Preview

Use the eye icon (bottom right) to preview while building.

Yes, you can dictate directly into your Treatment Note free text box.

Since we are a true web-based software, you have numerous dictation options that are already built into the computing devices you use.

On ChiroSpring, wherever you see a memo field on Treatment Templates, simply click in the memo field and the dictation software already running on your device is accessible. Sometimes you will need to activate your computing devices' dictation features. 

You can also use any browser extension. Dragon offers a Google Chrome Web Browser Extension. After you click in a memo box, just click or touch your browser extension icon to activate your mic. (Assuming you have downloaded the extension, logged into your account and established any settings like connecting your mic). 

Start by clicking in a memo field.

For iPads and Tablets

For a Windows Device

In order to properly invoke the dictation panel, make sure to place the mouse cursor on any text field, and then use the Windows key + H shortcut. When the voice dictation panel appears, and you see the microphone icon in blue, you can immediately start dictating.

Typically your device has already been listening to how you talk and quickly develops voice files that improve accuracy. Medical terms are not an issue. There is no need for you to buy, maintain or update any dictation software. The dictation software comes free through the operating system of your device. And ChiroSpring does not create any barriers to dictation. You can control this the way you desire since ChiroSpring is cloud-based.

Moreover, every memo field that has received dictation, maintains the dictated notes in the memo field for the subsequent visit documentation. You can dictate one time for multiple subsequent visits. And tweak the dictation as you go. You can put macros into your notes, customized for that patient.

You can reuse sections instead of rebuilding them.

• Open a Custom Template and Click Copy Section

• Open another Custom Template and Click Paste Section

When finished building:

• Click Save as Draft to continue later
• Click Finish to publish for clinic use

To duplicate a template:

• Go to Clinic Settings > Custom Templates > Templates List
• Click Clone

Providers have fast ways to start documentation:

• Click the patient’s name on the Scheduler or Front Desk to go to the Treatment Dashboard for that patient. From here you can click Template to left to open a new note or click the EHr menu.
• Drop down Notes from Front Desk Checked In column and select template to open a new note
• From the Provider Mobile App

All routes bring you to the Template List. When you open a new template for a patient, you are starting a NEW NOTE.  Doc Edits on the Patient Treatment Dashboard will have Today's already started or completed note to access and reopen.  

You can also REOPEN a Note:

• From the Front Desk for that day
• Patient File - Treatment Notes
• Patient File - Treatment Dashboard
  • Doc Edits or under Records
• Communication
  • Under Records
• Reports
  • Visit Compliance Report

Documenting the Visit

1. Select the appropriate template
2. Today’s date loads automatically
3. Previous visit data will auto-ditto (salt) by default. The template will start the way it was left last
   1. By default based on your Treatment Note Settings (by provider or regardless of provider)
4. Select the data points true for today
5. Save or Save and Sigh the template
6. Complete the Fee Slip and Save OR Cancel the Fee Slip if you aren't ready to documents ICD/CPT codes yet

Only selected items appear in the final printed/readable output.

REPORTS - Visit Compliance Report:

This report will ensure scheduled visits were completed, notes signed and claims generated.

Many providers love this report to : Tracking Unsigned Notes

Filter by Date Range, Patient, and choose to show

• Only Missing Content
• Excuse no/show/cancellations
• Require Note creation before Fee Slip/Claim Creation

Click SEARCH in upper, right

You can click on the Note, it will open and can update, Save and Sign

If a note (or fee slip/claim) hasn't been started, you can click this (+) icon and it will open Patient Treatment Dashboard, when you choose a note Template it will pull the DOS from the report automatically and you can complete note, save/sign and will ask if you want to attach the fee slip

You can also filter for Unsigned Notes from your Front Desk Screen

• Front Desk (Click the Three Dots next to the #4 by Check-out with claim

Final Takeaway

For most clinics:

• Use built-in templates for speed and compliance
• Use Super Note for maximum flexibility
• Use Custom Templates when you truly need full control

ChiroSpring gives you:

• Automation (SALT)
• Flexibility (Custom Builder)
• Efficiency (Super Note)
• Compliance tracking (Save & Sign + Reports)

You can keep things simple… or you can design the Mona Lisa of SOAP notes. Just remember, the fancier it gets, the more likely someone forgets to sign it. And auditors do not appreciate your artistic layout choices.

BONUS:

Click Here to Learn More about Advanced Dittos

ChiroSpring 360 provides over 50 professional treatment note templates.  You can also build your own treatment note (SOAP Note) template from scratch.  

Understanding the need for one single template that could work on every single visit, we developed the concept of a Super Note.  The video below will show you how to use the Super Note in ChiroSpring 360 as well as how to customize it to meet your individual needs.  

Super Note Video

Below you can see a screenshot of the Cervical Orthopedic tests.  

The next two screenshots below show the list of collapsed evaluations we offer.  You can customize these to meet your individual needs. 

The output of your note (in readable printable format) will only display the content that you selected during the Edit SOAP process. 

Key Points

• You can use the Super Note on ever single visit.  Information from the previous note will auto SALT (ditto) into today's note.  
• Make sure you exclude evaluations on the next visit (if they are not also done in today's visit).  You can always PULL THEM IN (include) the next time you do an exam.  They will SALT (ditto) over when you pull them in.  The exclude or include option is done by clicking the 

In the image below you can see the green checkmark.  This means this section's data will be included in today's note.  

In the image below I have clicked the green checkmark and turned it into a red -.  Now it will not be included in todays' note.  The next time I want to include it simply click the red - and it will copy into today's note from that last evaluation.