What should a chiropractic SOAP note include, and can an AI scribe write it?

The Hanah team · 12 September 2026

The short answer: a chiropractic SOAP note records what the patient told you (Subjective), what you found (Objective), what you think is going on (Assessment) and what you did and agreed next (Plan). It should also show the consent you obtained, the regions or segments you treated, the technique you used and how the patient responded. An AI scribe can draft most of that from the conversation in the room. It can't record what was never said out loud, and you stay responsible for what goes into the record.

The rules changed recently. The Chiropractic Board of Australia retired its Guidelines for clinical record keeping for chiropractors on 1 December 2025, but plenty of templates, courses and AI answers still quote them. Below is what applies now.

We build Hanah, an AI scribe for chiropractors, so read this with that in mind. The regulatory sources are linked throughout so you can check them.

What does the Chiropractic Board of Australia expect in a clinical record now?

There's no longer a records guideline written just for chiropractors. The Board retired it after a public consultation, noting that the decade-old guidelines could be considered overly prescriptive and included outdated references. It now points chiropractors to section 8.3 of the shared Code of conduct and to Ahpra's Managing health records resources, which the Chiropractic Board and seven other National Boards developed or approved.

Taken together, those documents ask for records that are:

accurate, up to date, factual, objective and legible
made at the time of the consult, or as soon as possible afterwards
clear to another practitioner, with your management plan included, so someone else could pick up the care
clear about the date and time, who provided the service and, where relevant, where it was provided
respectful, with nothing demeaning or judgemental
explicit about informed consent for examinations and treatment

Less prescriptive isn't a lower bar. You choose the layout, and the substance still has to be there.

What goes in each section of a chiropractic SOAP note?

Subjective. The presenting complaint in the patient's words, onset and history, aggravating and easing factors, relevant medical history and medications, the red-flag screening you did and what it showed, and the patient's goals. On a return visit, add how they've been since last time and how the home advice went.

Objective. What you assessed and what you found, with numbers where you have them: posture, range of motion, palpation and motion findings by region or segment, the orthopaedic and neurological tests you did and their results, and any outcome measure scores. Record only what you actually assessed.

Assessment. Your working diagnosis or clinical impression. On a return visit, whether progress matches what you expected.

Plan. Consent for today's treatment. The regions or segments treated and the technique used. The patient's response, including any adverse reaction. Home advice and exercises. The review or re-examination date. Any referral or co-management.

How do you document consent for a chiropractic adjustment?

Write down what you explained, what the patient asked and what they decided. Section 4.2 of the shared Code of conduct asks you to get informed consent before examining or treating. It says that consent should cover material risks and expected outcomes, and that you should document it, considering written consent for higher-risk procedures.

In practice, a consent entry usually shows:

what you explained: the proposed treatment, its material risks, the expected benefits, and the alternatives, including no treatment
the patient's questions and your answers
their decision, and whether consent was verbal or written
when you confirmed it again, for example for a new region, a new technique or a changed plan

New Zealand and the UK say much the same. The Chiropractic Board of New Zealand's Code of Ethics (July 2026) says verbal consent is usually enough for most procedures, but it should be documented in the patient's records. It also says a signed, non-specific consent to any future treatment is not acceptable, and that consent is needed for every new treatment plan or when the patient's circumstances change. In the UK, the General Chiropractic Council's Code of Professional Practice, in effect from 1 January 2026, requires you to obtain and record valid consent before you start or change care, and to tell patients about risks, benefits, alternatives and the expected natural history.

What should a re-examination note add?

A re-examination note should show whether care is working, and why it should continue, change or stop. The Board's fact sheet on duration and frequency of care lists what periodic review should include:

validated objective and subjective outcome measures
an evaluation of the benefit of care to the patient
whether the original diagnosis or impression should change
the clinical justification for continuing care, or not
the number of further visits proposed
the patient's understanding of, and agreement to, the proposed program of care

The UK Code similarly asks for formal reassessments at regular intervals using recognised outcome measures.

If a patient chooses regular care without symptoms, the same fact sheet expects you to give them a balanced, evidence-based view of the clinical justification. Record that conversation too.

Can an AI scribe write a chiropractic SOAP note?

Mostly, yes, as long as it's said in the room. A scribe drafts the note into your headings from the conversation: the history, the patient's description of their pain, the tests you name as you do them, what you explain about risks and what you agree for home.

There are three things it can't do:

Record what you don't say. Palpation findings you keep in your head, a segment you adjust without naming it, and reasoning you never voice aren't in the audio. Saying findings aloud as you go ("restricted at L4/5 on the left") helps the note, and often the patient.
Know what happened at another visit. If you discussed risks at the initial consult, today's recording won't contain it. Check the draft records what's true of today, nothing more.
Take responsibility for the record. Ahpra's guidance on using AI in healthcare says that if you use an AI scribe, you're responsible for checking the accuracy and relevance of the records it creates.

Here's how that works in Hanah. A chiropractor's starter library has an initial assessment and a progress note in SOAP format, a referral letter and a discharge summary. The SOAP template asks for objective findings one per line, with figures and units, and tells the AI to leave out anything that wasn't assessed. Templates are editable, so if you want consent, regions treated, technique and response on their own lines, add those headings and Hanah fills them from the consult. Progress notes start in clinical shorthand, which suits a short follow-up. Hanah doesn't file anything automatically: a note reaches your practice-management system only when you send it.

Do you also need the patient's consent to use the AI scribe?

Yes, and it's separate from consent to treatment. Ahpra's AI guidance says a generative-AI scribe will generally need the patient's informed consent, and that you should ideally note the patient's response in the record. It also warns that recording a consultation without consent may have criminal implications. The UK Code lists making a recording of a patient among the things you need recorded consent for.

A short line in the note, such as "Consented to AI scribe for this consult", is a simple way to capture it.

What does a finished note look like?

Here's a fictional return visit as a shorthand progress note, after the chiropractor reviewed the draft:

S: Visit 3. L-sided LBP, 3/52. NPRS 4/10 (6/10 at initial). Sitting tolerance ~45 min (was ~20). No leg sx. Walking 20 min most days as advised.

O: Lumbar flexion ~75%, end-range pain L. Restricted and tender L4/5 L. SLR neg bilat. LL neuro screen unremarkable.

A: Mechanical LBP, improving as expected.

P: Consent: verbal consent reconfirmed today for lumbar side-posture adjustment; risks, benefits and alternatives discussed at initial visit. Tx: L4/5 L side-posture HVLA; soft tissue L QL and gluteals. Tolerated well, no adverse response. Home: continue walking; add hip mobility 2×10 daily. Re-exam at visit 6 with NPRS and ODI. Pt agrees with plan. Consented to AI scribe for this consult.

The S, O and A sections were all said aloud, so the scribe could draft them. The line about the initial visit's risk discussion came from the chiropractor, because that conversation wasn't in today's recording.

FAQ

Does the Chiropractic Board of Australia still have record-keeping guidelines? Not chiropractic-specific ones. They were retired on 1 December 2025. The shared Code of conduct (section 8.3) and Ahpra's Managing health records resources now set out what's expected.

Do I need written consent for every adjustment? The shared Code doesn't require written consent for every treatment. It asks you to document consent and to consider written consent for higher-risk procedures. Your professional indemnity insurer may have its own expectations, so check with them.

Is an AI scribe regulated by the TGA? Ahpra's guidance says AI scribes are usually general-purpose tools that don't meet the definition of a medical device, so they generally aren't regulated by the TGA. That doesn't change your responsibility for the record.

Can an AI scribe invent findings? Any AI can make errors, which is why every draft needs your review. We publish our measured error rates in a standing accuracy and hallucination report, worst results included. Ask any vendor for theirs.

If you'd like to see this with your own templates, see Hanah for chiropractors or book a demo below.