Provider Treatment Notes in ChiroSpring 360

The Complete How-To Guide

ChiroSpring gives you two powerful options for provider documentation:

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

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

Choosing & Activating Treatment Templates

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

How Providers Document a Visit

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.

Creating a Custom Treatment Note (SOAP Template)

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
3. Click Build Templates
4. Choose form type (Provider, Patient App, Kiosk, Webforms, etc.)

5. Name the template

   Choose category

   Set Treatment Note Order (controls display order on Dashboard)

   Choose your starting point:

   • Start from scratch
   • Start from predefined template
   • Start from existing custom template
6. Click Build

Next you'll be prompted to choose which type of form you would like to build:

Each form option includes the same builder technologies, and you may utilize templates to start with for each type of note/form.

Next, name the template and choose the category for the template. This will impact where you can locate your custom template in your Treatment Notes page in the Setup menu. The Treatment Note order box allows you to enter a numeric indicator for the ordering of your template in relation to other active templates on the Treatment Dashboard when you navigate to a patient file.

Next, choose your custom template starting point. You can start from scratch, choose to start from an existing template option from our list of predefined templates, or you can choose to start from an existing custom template you have already created.

Template Builder Controls

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)
• Note: Checkbox labels should be descriptive at each level to display best in the note output (i.e. if doing Checkboxes for Pain areas, label could read "Shoulder Pain, and the sublevel check boxes should could read "Shoulder pain right side, Shoulder pain left side" to read better than just Right and Left. 
• Radio Group - This option allows for only ONE selection when documenting your note.  If you desire multiple selections use the check-box option instead.
• Labels (Field label without additional text input)
• Paragraph (descriptive content for note template)
• Date picker (i.e. choosing date for onset date)
• Time picker (i.e. noting start time of rehab exercises)
• Adjustment strip

• 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
• Ai Scribe

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.

Layout & Organization

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.

Copying Sections Between Templates

You can reuse sections instead of rebuilding them.

• Open a Custom Template and Click Copy Section

• Open another Custom Template and Click Paste Section

Saving & Publishing Custom Templates

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

Save & Sign Provider Treatment Notes

In a busy practice, completing your SOAP note in real-time may not always occur.  Complex patients need more documentation as do exams or PI visits.  This is why ChiroSpring provides a feature to sign off on a note, signifying it is complete.  This allows the doctor time to both start the note and see the patient, and remind them the note is not complete.  This feature will ensure your notes are 100% complete, something you’ll want, should you ever be audited.

Tracking Unsigned Notes

To protect against audit risk ChiroSpring has two ways to quickly find unsigned notes:

• Visit Compliance Report

• 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 Super Note

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.