Acupuncture SOAP Note

Visit Information

Date of Service: [Date]

Visit Type: [New / Established]

Provider: [Provider name and credentials]

Chief Complaint: [Chief complaint in patient's own words] (Use patient's wording when available; if unavailable, provide a concise summary without inventing quotations.)

Safety Screening: [Pregnancy status, anticoagulant/bleeding risk, pacemaker/ICD status as relevant] (Include only items relevant to today's treatment; omit this field entirely if none are relevant. Document "not assessed" only for high-safety items that were relevant but not obtained.)

Subjective

[Interval history since last visit] (For established visits: document symptom change with magnitude, duration of benefit from prior treatment, functional changes, and any adverse reactions from last session. Focus on updates; avoid repeating full history.)

[History of present illness] (For new visits or new complaints: include location, quality, severity with numeric scale, duration, timing, aggravating/alleviating factors, associated symptoms, relevant red flags, and functional impact.)

[Patient-stated treatment goals and preferences] (Document goals in measurable terms when possible; include preferences affecting the plan such as tolerance for electroacupuncture, needle sensitivity, or positioning.)

TCM Pattern-Oriented Symptoms: [Temperature preference, sleep, digestion, mood, pain qualities such as fixed vs wandering or worse with cold/damp] (Include only if TCM pattern diagnosis will be used; otherwise omit this field entirely.)

Objective

General/Vitals: [Observation and vital signs] (Include only when clinically indicated; do not auto-populate normal findings.)

Focused Examination: (Note laterality throughout; document only clinician-observed findings.)

• [Inspection findings] (Swelling, discoloration, deformity, scars)
• [Palpation findings] (Tender points, trigger points, taut bands with anatomical landmarks)
• [Range of motion with pain provocation] (Degrees if measured; note where pain begins/ends)
• [Neurological findings] (Include only when indicated: strength, sensation, reflexes, special tests)

TCM Objective Assessment: (Include only if performed; omit entirely if not assessed.)

• Tongue: [Color, shape, coat, notable features]
• Pulse: [Rate, depth, quality descriptors]

Assessment

(List each problem addressed today in priority order. For ongoing treatment series, document measurable symptom and functional trends to support medical necessity—required for Medicare cLBP coverage beyond initial 12 sessions.)

[Problem 1]: [Biomedical diagnosis, ICD-10 aligned]

Status: [improving / stable / worsening]

Supporting findings: [Key evidence from Subjective and Objective]

TCM pattern: [Pattern name with supporting features / pattern assessment deferred] (Include only if using TCM; cite features documented above. If insufficient data, state "pattern assessment deferred" rather than inferring.)

Trend summary: [Measurable symptom and functional trends] (Include for active treatment series; use numeric scales and time-bound changes when available.)

(Repeat structure for each additional problem addressed.)

Plan

(Every problem in Assessment must have corresponding plan elements. Do not include plan items without an assessed problem.)

Consent

[Informed consent obtained / reconfirmed]; [Special precautions if applicable] (e.g., pregnancy-related point avoidance, bleeding risk mitigation, device considerations.)

Treatment Rendered

Technique: [manual acupuncture / electroacupuncture]; Position: [supine / prone / side-lying / seated]

Points: [Points with laterality, grouped by region or intention; include ashi points with anatomical description]

Needle count: [Needles in] / [Needles out] (Verify counts match.)

Electroacupuncture parameters: [Lead placement, frequency, intensity, duration; contraindication check completed] (Include only if electroacupuncture used; omit otherwise.)

Adjunctive therapies: [Method, location, duration for each therapy performed] (Include only therapies actually performed: moxibustion, cupping, gua sha, heat lamp, ear seeds. Omit this field if no adjuncts used.)

Response

[Immediate patient response and tolerance]; [Adverse events if any: onset, symptoms, actions taken, follow-up plan] (If no adverse events, document "tolerated well.")

Aftercare

[Expected soreness/bruising, activity guidance, warning signs requiring urgent care]

Follow-up

Recommendations: [Visit frequency and duration, home program if applicable, referrals if indicated]

Next appointment: [Date if scheduled]

Billing/Time Documentation

[Total treatment time, needle retention time, reinsertion if applicable, time-based modalities] (Include fields required by billing workflow; keep separate from clinical narrative.)

Signature: [Provider name, credentials, date/time signed]