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Never paste real patient data into Claude. Always use de-identified or fictional details when building your notes. Once Claude generates the draft, you can insert actual patient specifics into your EHR. HIPAA applies to every AI tool, and Claude conversations are not a secure medical record.
Include measurable objective findings. Palpation tenderness, range of motion in degrees, and orthopedic test results give Claude the raw material to write notes that withstand insurance audit. "Sore back" produces a weak note; "lumbar flexion 35/60, positive Kemp's right" produces a defensible one.
Match your documentation to your technique system. If you practice Gonstead, include Gonstead listings and terminology. If you use Activator, reference instrument-assisted adjustments. Claude adapts to whatever system you describe — just be consistent.
Review every note before signing. AI-generated clinical documentation is a first draft, not a finished product. Check that subjective history matches what the patient actually reported, that objective findings are accurate, and that the assessment logically supports the plan. You are the provider of record.
Save your best prompts as templates. Once you dial in a prompt that consistently produces notes matching your style, save it in a text expander or your EHR's macro system. This turns a 60-second process into a 10-second one for routine visits.
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5 Claude Prompts for SOAP Notes — Chiropractors
Ready-to-use Claude prompts for drafting chiropractic SOAP notes, initial evaluations, and progress documentation that save hours of after-hours charting.
Why Use AI for SOAP Notes?
Clinical documentation is one of the biggest time drains in chiropractic practice. Most DCs spend 30 minutes to over an hour each evening catching up on SOAP notes, re-examination reports, and progress summaries. That is time taken directly from your family, your recovery, or your ability to grow the practice. Claude can generate a structured first draft of a SOAP note in under a minute when you feed it the right clinical details.
These prompts are built around real chiropractic workflows — not generic medical templates. They use terminology familiar to chiropractic documentation: subluxation listings, spinal regions, adjustment techniques, and functional outcome measures. You still need to review, verify, and sign off on every note, but the heavy lifting of organizing findings into a clean narrative is handled for you.
The key is giving Claude specific clinical inputs. Vague prompts produce vague notes. When you include objective findings like range of motion values, orthopedic test results, and palpation findings, the output is dramatically more useful and audit-ready.
The Prompts
Prompt 1: Daily Encounter SOAP Note
Use this for routine adjustment visits with established patients.
You are a chiropractic documentation assistant. Write a complete SOAP note for a daily chiropractic encounter using the details below. Use standard chiropractic terminology and format the note with clear S, O, A, and P sections.
Patient details:
- Chief complaint: [e.g., low back pain with bilateral radiation into gluteal region]
- Reported pain level today: [X/10]
- Subjective changes since last visit: [e.g., patient reports 30% improvement, sleeping better, still aggravated by prolonged sitting]
Objective findings:
- Subluxation listings found today: [e.g., L4 PRS, L5 PRI, SI joint fixation right]
- Spinal regions adjusted: [e.g., lumbar spine, sacroiliac joint]
- Technique(s) used: [e.g., Diversified, Thompson drop, flexion-distraction]
- Additional therapies: [e.g., electrical muscle stimulation 15 min, ice pack 10 min]
- Palpation findings: [e.g., moderate hypertonicity bilateral lumbar paraspinals, tenderness at L4-L5]
- ROM observations: [e.g., lumbar flexion moderately restricted, extension mildly restricted]
Instructions:
- Assessment should reference functional improvement or lack thereof
- Plan should include next visit frequency and any home care recommendations
- Keep the note concise — under 250 words total
- Use present tense for objective findingsExample Output:
S: Patient presents for scheduled adjustment reporting low back pain at 5/10, down from 7/10 at last visit. States he is sleeping through the night more consistently and tolerating 30-minute walks without flare-up. Prolonged sitting beyond 45 minutes at his desk still aggravates symptoms, particularly in the bilateral gluteal region.
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O: Palpation reveals moderate hypertonicity of bilateral lumbar paraspinals with focal tenderness at L4-L5. Subluxation listings: L4 PRS, L5 PRI, right SI joint fixation. Lumbar flexion moderately restricted, extension mildly restricted. Adjustments delivered to L4, L5, and right SI joint using Diversified technique and Thompson drop. Electrical muscle stimulation applied to lumbar region for 15 minutes followed by ice pack for 10 minutes.
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A: Patient demonstrates 30% subjective improvement over the current treatment phase. Functional gains noted in sleep quality and walking tolerance. Restricted lumbar ROM and recurring subluxation patterns indicate continued corrective care is warranted.
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P: Continue adjustments 2x/week for the next two weeks. Patient instructed to perform lumbar extension stretches at home and use a lumbar support cushion when sitting at his workstation. Re-evaluate progress at visit 12.
Prompt 2: New Patient Initial Evaluation
For comprehensive day-one documentation including history and examination findings.
Write a chiropractic initial evaluation report for a new patient based on the following intake and examination data. Structure it as: History of Present Illness, Past Medical History, Examination Findings, Assessment, and Plan.
Patient information:
- Age/sex: [e.g., 42-year-old female]
- Chief complaint: [e.g., neck pain and headaches for 3 weeks following a slip and fall at home]
- Onset/mechanism: [e.g., fell on outstretched hand, landed on right side, immediate neck stiffness]
- Pain location and character: [e.g., bilateral cervicothoracic junction, sharp with rotation, dull at rest]
- Pain rating: [X/10]
- Aggravating factors: [e.g., looking over shoulder, working at computer, overhead reaching]
- Relieving factors: [e.g., ice, rest, ibuprofen provides mild temporary relief]
- Prior treatment: [e.g., PCP prescribed muscle relaxer, no imaging ordered]
- Relevant past medical history: [e.g., prior MVA in 2019, no surgeries]
Examination findings:
- Postural analysis: [e.g., right head tilt, elevated right shoulder, mild anterior head carriage]
- ROM measured: [e.g., cervical flexion 40/50, extension 30/60, right rotation 55/80, left rotation 60/80]
- Orthopedic tests: [e.g., cervical compression positive right, Spurling's negative bilateral, shoulder depression positive right]
- Neurological: [e.g., upper extremity reflexes 2+ bilateral, grip strength 5/5 bilateral, dermatomes intact]
- Subluxation findings: [e.g., C5 PRS, C6 PLI, T1 PRI]
- Palpation: [e.g., severe hypertonicity right upper trapezius and levator scapulae, moderate tenderness C5-T1 facet joints right]
Instructions:
- Use professional clinical language suitable for insurance review
- Include an initial assessment with ICD-10 diagnostic impressions as placeholders (e.g., M54.12)
- Recommend a treatment plan with visit frequency, duration, and short-term goals
- Target 350-450 wordsExample Output:
History of Present Illness: This 42-year-old female presents with a three-week history of neck pain and occipital headaches following a slip and fall at home. The patient reports landing on her right side with an outstretched hand, experiencing immediate neck stiffness. Pain is located at the bilateral cervicothoracic junction, described as sharp with rotation and dull at rest, rated 7/10. Symptoms are aggravated by looking over the shoulder, computer work, and overhead reaching. Ice, rest, and ibuprofen provide mild temporary relief. Her PCP prescribed a muscle relaxer; no imaging has been ordered. Relevant history includes a prior MVA in 2019 with no surgical interventions.
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Examination Findings: Postural analysis reveals right head tilt, elevated right shoulder, and mild anterior head carriage. Cervical ROM: flexion 40/50, extension 30/60, right rotation 55/80, left rotation 60/80. Cervical compression test positive on the right. Spurling's test negative bilaterally. Shoulder depression test positive on the right. Upper extremity reflexes 2+ bilaterally, grip strength 5/5 bilaterally, dermatomes intact. Subluxation listings: C5 PRS, C6 PLI, T1 PRI. Palpation reveals severe hypertonicity of the right upper trapezius and levator scapulae with moderate tenderness at C5-T1 facet joints on the right.
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Assessment: Cervical segmental dysfunction (M99.11), cervicalgia (M54.2), cervicogenic headache (G44.86). Clinical findings are consistent with post-traumatic cervical sprain/strain complicated by underlying segmental dysfunction. Neurological examination is unremarkable, and radiculopathy is not suspected at this time.
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Plan: Initiate corrective care at 3x/week for 4 weeks, then reassess. Treatment will include Diversified adjustments to the cervical and upper thoracic spine, electrical muscle stimulation, and ice therapy. Short-term goals: reduce pain to 4/10, restore cervical rotation to 70 degrees bilaterally, and improve workstation tolerance to 2 hours without symptom exacerbation within 30 days. Home care instructions provided including cervical retraction exercises and ergonomic workstation modifications.
Prompt 3: Progress / Re-Examination Note
For documenting patient status at the end of a treatment phase, typically every 12-24 visits.
Write a chiropractic progress re-examination report comparing initial findings to current status. This will be used to justify continued care or transition to the next phase.
Re-exam context:
- Visit number: [e.g., visit 12 of initial 12-visit treatment plan]
- Treatment dates: [e.g., January 5 to February 25, 2026]
- Original chief complaint: [e.g., moderate-severe low back pain with right radiculopathy, rated 8/10]
- Current chief complaint status: [e.g., mild low back pain, no radiating symptoms, rated 3/10]
Comparative findings:
- ROM initial vs. current: [e.g., lumbar flexion 40 degrees initially, now 55 degrees; extension 15 degrees initially, now 25 degrees]
- Orthopedic tests initial vs. current: [e.g., SLR was positive right at 45 degrees, now negative bilateral]
- Functional outcome measure: [e.g., Oswestry Disability Index 48% initially, now 18%]
- Subluxation changes: [e.g., L5 subluxation reduced and holding, L4 still requiring correction each visit]
- Patient-reported functional gains: [e.g., returned to gym, able to sit through full workday without pain]
Instructions:
- Clearly show measurable improvement with percentages where possible
- State whether treatment goals were met, partially met, or unmet
- Recommend next phase: continued corrective care, maintenance, or discharge
- Keep under 300 words
- Write in a tone appropriate for insurance utilization reviewExample Output:
Re-Examination Summary — Visit 12 of 12
Treatment dates: January 5 through February 25, 2026
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Subjective: Patient reports significant improvement since initiating care. Low back pain has decreased from 8/10 to 3/10. Right lower extremity radiating symptoms have fully resolved. Patient states he has returned to his gym routine and can sit through a full 8-hour workday without pain.
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Comparative Objective Findings: Lumbar flexion improved from 40 degrees to 55 degrees (37.5% improvement). Lumbar extension improved from 15 degrees to 25 degrees (66.7% improvement). Straight leg raise was positive on the right at 45 degrees at initial evaluation and is now negative bilaterally. Oswestry Disability Index decreased from 48% (severe disability) to 18% (minimal disability), representing a 62.5% improvement. L5 subluxation has reduced and is holding correction between visits. L4 continues to require correction at each visit, indicating residual segmental instability.
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Assessment: Treatment goals have been partially met. Pain reduction and functional outcome targets have been exceeded. ROM has improved meaningfully but has not reached age-normal values. Persistent L4 segmental dysfunction warrants continued care to achieve full spinal stability.
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Recommendation: Transition to Phase 2 corrective care at 2x/week for 6 weeks. Focus on stabilization of L4 segment and continued ROM restoration. Updated short-term goals: lumbar flexion to 60 degrees, Oswestry score below 12%, and L4 subluxation holding correction for a minimum of 5 days between visits.
Prompt 4: Maintenance Care Documentation
For documenting supportive or wellness visits where the patient has reached maximum therapeutic benefit.
Write a chiropractic maintenance care SOAP note that documents the rationale for ongoing periodic adjustments. This note must support medical necessity for preventive or supportive care.
Patient context:
- Condition history: [e.g., chronic degenerative disc disease L4-L5 and L5-S1, history of two acute episodes per year prior to chiropractic care]
- Current status: [e.g., patient is at maximum medical improvement, pain 1-2/10 on most days]
- Maintenance frequency: [e.g., every 3 weeks]
- Today's subjective: [e.g., mild stiffness after yard work, no acute flare, overall managing well]
Today's objective findings:
- Subluxations found: [e.g., L5 PLI — recurrent listing, mild fixation]
- Technique used: [e.g., Gonstead, side-posture lumbar adjustment]
- Additional therapy: [e.g., none today]
- Palpation: [e.g., mild hypertonicity left lumbar paraspinals]
Instructions:
- Assessment should explain why periodic care prevents deterioration
- Reference the patient's history of flare-ups without regular care
- Plan should confirm maintenance schedule and any seasonal considerations
- Keep under 200 wordsExample Output:
S: Patient presents for scheduled maintenance visit reporting mild low back stiffness following yard work over the weekend. No acute flare-up. Overall managing well and reports no episodes of severe pain since transitioning to maintenance care four months ago. Current pain 1/10.
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O: Palpation reveals mild hypertonicity of left lumbar paraspinals. Subluxation listing: L5 PLI with mild fixation, consistent with recurrent pattern. Adjustment delivered to L5 using Gonstead side-posture technique. No additional therapies administered today.
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A: Patient remains at maximum medical improvement with chronic degenerative disc disease at L4-L5 and L5-S1. Prior to initiating chiropractic maintenance care, the patient averaged two acute flare-ups per year requiring intensive treatment. Since beginning periodic adjustments, the patient has experienced zero acute episodes over the past 10 months. Recurrent L5 subluxation pattern confirms the need for ongoing supportive care to maintain spinal function and prevent exacerbation.
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P: Continue maintenance adjustments every 3 weeks. Patient advised to stretch before prolonged physical activity and maintain core exercise program. Spring yard work season may warrant temporary increase to every 2 weeks if symptoms escalate.
Prompt 5: Multi-Region Treatment Note
For visits where multiple spinal regions and extremities are treated.
Write a chiropractic SOAP note for a visit involving adjustments to multiple spinal regions and one extremity. Organize objective findings by region for clarity.
Patient subjective:
- Primary complaint: [e.g., mid-back stiffness and right shoulder pain, 5/10]
- Secondary complaint: [e.g., intermittent neck tension, 3/10]
- Reported changes: [e.g., shoulder improving gradually, mid-back flared after lifting boxes at work yesterday]
Objective findings by region:
- Cervical: [e.g., C2 AS right, mild fixation; adjusted with Diversified rotary break]
- Thoracic: [e.g., T5-T7 posterior fixation bilateral; adjusted with Diversified prone, anterior thoracic technique]
- Right shoulder: [e.g., restricted glenohumeral internal rotation; adjusted with long-axis distraction and mobilization]
- Palpation: [e.g., moderate hypertonicity bilateral rhomboids, mild tenderness right supraspinatus]
- Therapies applied: [e.g., ultrasound to right shoulder 5 min, moist heat to thoracic spine 15 min]
Instructions:
- Format the Objective section with subheadings for each region treated
- Assessment should tie all regions together functionally where relevant
- Plan should address each complaint area
- Keep under 300 wordsExample Output:
S: Patient reports mid-back stiffness at 5/10 and right shoulder pain at 5/10 as the primary complaints. Secondary complaint of intermittent neck tension at 3/10. States the shoulder has been improving gradually over the past three visits but mid-back flared yesterday after lifting boxes at work. Neck tension is positional and mild.
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O:
Cervical: C2 AS right with mild fixation identified on motion palpation. Adjusted with Diversified rotary break technique. Post-adjustment motion improved.
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Thoracic: T5-T7 posterior fixation bilaterally with moderate hypertonicity of bilateral rhomboids. Adjusted using Diversified prone technique with anterior thoracic contact. Moist heat applied to thoracic spine for 15 minutes.
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Right Shoulder: Restricted glenohumeral internal rotation noted. Long-axis distraction and joint mobilization performed to the right glenohumeral joint. Mild tenderness over right supraspinatus on palpation. Therapeutic ultrasound applied to right shoulder for 5 minutes at 1.0 W/cm2.
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A: Patient presents with multi-region musculoskeletal dysfunction involving the cervical spine, thoracic spine, and right shoulder. Mid-back exacerbation is consistent with mechanical overload from occupational lifting. Shoulder mobility is trending toward improvement. Cervical complaint remains stable and mild. All regions demonstrate functional interconnection through the posterior chain and upper crossed posture pattern.
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P: Continue current treatment frequency of 2x/week. Cervical: monitor C2 fixation pattern, no frequency change needed. Thoracic: instruct patient on proper lifting mechanics and prescribe foam roller extension exercises. Right shoulder: continue mobilization and ultrasound; add rotator cuff isometric strengthening exercises at home. Reassess all three regions at visit 10.