Integrative Medicine SOAP Note

Integrative Medicine SOAP Note (Progress)

(Use respectful, plain language suitable for patient access. Omit sections not addressed today. Avoid autopopulated normal findings. For high-salience safety items not assessed, explicitly note "not assessed today" rather than omitting.)

Date: [Date of service]

Patient: [Patient name and identifier]

Provider: [Provider name, credentials]

Encounter Type: [new / established] • [in-person / telehealth]

Chief Concern: [Patient's primary concern in their words]

Visit Goals: [1–3 concise goals for today's encounter]

Subjective

HPI: [Narrative of chief concern including onset/course, symptom descriptors, functional impact, what patient has tried including integrative modalities, and responses] (Include pertinent negatives only when clinically meaningful.)

Lifestyle Review: [Summary of domains addressed today—nutrition, movement, sleep, stress/mental health, social connection, substance use—with current status and changes] (Only include domains discussed; omit this section if no lifestyle review performed.)

Integrative Therapies in Use: [Complementary therapies with frequency and perceived benefit] (Omit if none.)

Medications & Supplements: [All Rx, OTC, and supplements/botanicals with product name, dose/formulation, frequency, and indication] (Note adherence is patient-reported; include brand/standardization for supplements when available.)

Allergies: [Medication and supplement allergies with reaction type]

ROS: [Targeted review relevant to today's concerns] (Omit if not performed.)

Objective

Vitals: [Relevant vitals as available] (Note if patient-reported for telehealth.)

Exam: [Pertinent positives and negatives by system] (Document only systems examined.)

Data: [Relevant labs, imaging, validated scales, or patient-reported measures reviewed today with dates and key values]

Assessment

(List problems in order of clinical importance. Avoid declaring unvalidated root causes as facts.)

[Problem 1]: [Diagnosis/clinical impression] — [improved / stable / worsened / new]

Supporting evidence: [Brief S and O highlights]

Clinical reasoning: [Concise synthesis; include differential if relevant]

Whole-person contributors: [Sleep, stress, nutrition, deconditioning, social factors as applicable] (Omit if not applicable.)

Safety considerations: [Pregnancy/lactation, anticoagulants, hepatic/renal function, polypharmacy, interactions] (State "not assessed today" for relevant items not evaluated.)

[Problem 2]: [Diagnosis/clinical impression] — [status]

(Follow same structure as Problem 1. Add additional problems as needed.)

Plan

(Organize by problem, mirroring Assessment.)

[Problem 1]

Diagnostics: [Tests ordered with rationale and timing] (Omit if none.)

Therapeutics: [Conventional medications/devices with dose, frequency, duration, safety/monitoring]

Lifestyle interventions: [Nutrition, movement, sleep, stress management recommendations with specific targets and practical steps]

Mind-body practices: [Meditation, yoga, tai chi, etc. with style, frequency, and realistic starting dose] (Omit if none.)

Supplements/Botanicals: [Product name, formulation, dose, frequency, duration, indication, key risks, interaction screening performed with source/date, monitoring parameters, stop criteria] (Document with medication-level rigor. Omit if none.)

Referrals: [Specialists, health coaches, community resources with purpose and urgency] (Omit if none.)

Procedures performed: [Procedure, consent discussion, technique, tolerance, post-procedure instructions] (Only include if performed today.)

[Problem 2]

(Follow same structure. Add additional problems as needed.)

Patient Education: [Options discussed, patient preferences, shared decision reached, materials provided]

Follow-up: [Interval, modality, what to track between visits, pre-visit labs if any]

Return Precautions: [Red flags warranting urgent or emergent evaluation]

Time

(Include only when using time-based billing.)

Total clinician time on date of service: [Exact minutes] (Use single number, not a range.)

Separately billable counseling time: [Minutes and topic] (Only if applicable.)