Naturopathic Follow-Up Progress Note (SOAP, In-Person or Telehealth)

Encounter Information

Encounter Date: [Date]

Author/Credentials: [Name, credentials]

Encounter Type: Established patient follow-up

Setting: [In-person / Telehealth]

Reason for Visit: [Primary reason for visit]

Participants: [Patient alone / with family or caregiver; interpreter: Yes – language and modality / No]

Telehealth Attestation

(Include only if Setting is Telehealth. If any element cannot be confirmed, document "Not documented: [reason]" rather than omitting.)

• Modality: [Synchronous video / Audio-only]
• Patient location: [State, setting]
• Clinician location: [State]
• Consent obtained: [Verbal / Written]
• Identity verification: [Method used]
• Exam limitations: [Limitations inherent to telehealth and impact on diagnostic certainty]

Subjective

Chief Concern: [Patient's own words] (Include direct quote when clinically meaningful.)

Interval History since [prior visit date]: [Response to prior plan including adherence and perceived benefit; symptom evolution with functional impact; patient goals and preferences for this visit]

Lifestyle and Self-care: [Sleep, nutrition, stress, activity, substance use as relevant to today's plan] (Include only elements that inform the plan.)

Medications, Supplements, and Botanicals Reconciled: (Label data provenance.)

• [Item name; for botanicals include common and Latin name with plant part] — [formulation], [dose], [route], [frequency], [timing]; [start / stop / continue], [adherence notes]
• (Repeat as needed. If details unknown, document "dose TBD" or "patient to provide product label" with interim safety guidance. If reconciliation incomplete, document "Unable to reconcile fully: [reason]".)

Allergies/Intolerances: [Drug, supplement, or botanical and reaction type]

Focused Review of Systems: [Pertinent positives and negatives not already captured] (Include only if it adds new information.)

Objective

Vitals: [Relevant vitals with source: measured in clinic / patient-reported with timestamp] (If expected but not obtained, document "Not obtained: [reason]".)

Focused Exam: [Pertinent positives and negatives tied to clinical decisions] (For telehealth, document only observable findings and restate limitations.)

Diagnostics and Data Reviewed: [Test, result, date, source: internal / outside; clinically meaningful trends]

Orders Placed Today: [Test or imaging ordered with clinical purpose and patient preparation if relevant] (Include only orders actually placed today.)

Assessment

(List problems in descending clinical importance. Include status, evidence summary, and clinical reasoning. Note absence of red flags when this affects safety decisions.)

[Problem 1]: [Diagnosis or clinical impression] — [improving / stable / worsening / new]

[Evidence summary linking symptoms, exam findings, and data; contributing factors as hypotheses when relevant; differential if diagnosis uncertain]

[Problem 2]: [Diagnosis or clinical impression] — [improving / stable / worsening / new]

(Add additional problems as needed.)

Plan

(Organize by problem. Label start/stop/continue status compared with prior regimen.)

[Problem 1]

• Shared decision-making: [Key topics discussed; patient preferences incorporated]
• Lifestyle and Behavior: [Specific measurable steps; timeline for re-evaluation]
• Nutrition: [Actionable steps; elimination trial duration and stop conditions if applicable]
• Supplements and Botanicals: [Product: common name; botanical name with plant part] — [formulation], [dose], [route], [frequency], [timing], [duration], [taper or stop instructions]; Target: [symptom or biomarker]; Status: [start / continue / stop / modify]. Safety screening: [pregnancy/lactation, anticoagulant use, hepatic/renal status, upcoming surgery, allergy history, interaction risks, adverse effects to monitor]. (If details unknown, document "dose TBD" with interim safety guidance.)
• Medications: [Changes within scope; coordinate with PCP or specialist if outside scope]
• Tests and Imaging: [Test ordered]; Clinical question: [what to confirm or monitor]; Decision impact: [what result would change]
• Referrals: [Discipline]; Urgency: [routine / urgent]; Question: [consult question]; Records shared: [yes / no]
• Monitoring: [What to track, frequency, escalation thresholds] (For telehealth, specify what requires in-person evaluation.)
• Return precautions: [Red-flag symptoms and when to seek urgent or emergency care]

[Problem 2]

(Repeat elements as applicable.)

Follow-up: [Timeframe], [In-person / Telehealth], [Visit purpose], [Patient tasks before next visit]

Sign-off

Signature/Credentials: [Name, credentials]

Date/Time Signed: [Date and time]

(Omit sections not relevant to the encounter. Label data provenance throughout. Do not copy-forward content not re-verified during this encounter.)