Osteopathic SOAP Note (Office Visit)

Date: [date]

Patient: [patient name and identifier]

Provider: [provider name and credentials]

Visit Type: [new / established], [in-person / telehealth]

Allergies: [reconciliation status and pertinent allergens]

Medications: [reconciliation status and pertinent changes]

Subjective

Chief Complaint: [patient-stated clinical symptom with duration] (Document the symptom or condition, not a procedure. Do not use "OMT" or "manipulation" as the chief complaint.)

History of Present Illness: [narrative history] (Include onset, location, duration, character, aggravating and alleviating factors, severity, functional impact, prior treatments and response, relevant red flags considered, and patient goals. For established patients with stable chronic problems, note only pertinent updates rather than re-documenting unchanged history.)

Pertinent ROS: [targeted review of systems] (Include only if symptoms beyond the HPI materially affect the differential or management. Document pertinent positives and meaningful negatives. Omit this line entirely if no additional ROS was obtained.)

Objective

Vitals: [relevant measurements]

Physical Exam: [pertinent findings by system] (Document relevant positives and negatives aligned to the complaint. For musculoskeletal concerns, include inspection, palpation, range of motion, neuro screen, and provocative tests as appropriate.)

Osteopathic Structural Exam: [regions examined and TART findings with segmental or descriptive diagnoses] (Include when osteopathic structural exam is performed. If no significant somatic dysfunction identified, state briefly. Omit this line entirely if OSE was not performed.)

Data Reviewed: [pertinent labs, imaging, or external records with dates and key findings] (Omit if none reviewed.)

Assessment

(List problems in order of clinical priority. Provide brief rationale linking findings to each diagnosis. For somatic dysfunction, include region specificity and relationship to the presenting complaint.)

1. [Problem/Diagnosis]: [rationale linking subjective and objective findings]
2. [Problem/Diagnosis]: [rationale] (Continue as needed.)

Plan

(For each problem, address diagnostics, treatments, patient education, follow-up, and return precautions as applicable. Mirror numbering with Assessment.)

1. [Diagnostics ordered; treatments including medications with dosing, nonpharmacologic interventions, referrals; education and shared decision-making points; follow-up timing; return precautions]
2. [Plan for additional problems as needed]

[OMT discussed and deferred due to [reason]; interim management: [approach]] (Include only when OMT was discussed but not performed. Otherwise omit.)

E/M Time: [total minutes] (Include only if billing by time. Exclude time spent on separately billed procedures. Otherwise omit.)

OMT Procedure Addendum

(Include this section only when OMT is performed. Must be readable as a stand-alone procedure note. Omit entire section if OMT was not performed.)

Procedure: Osteopathic Manipulative Treatment (OMT)

Indication: [symptom and functional limitation linked to somatic dysfunction findings]

Consent: Informed consent obtained; risks, benefits, and alternatives discussed

Precautions Considered: [relevant contraindications screened]

Regions Treated: [body regions treated; total count determines CPT code level]

Findings in Treated Regions: [TART findings or segmental diagnoses for each treated region]

Techniques: [technique categories applied]

Response: [immediate symptomatic and/or objective response; patient tolerance]

Complications: [none / description]

Post-Treatment Instructions: [hydration, expected soreness, activity modifications, home exercises, follow-up timing, red-flag precautions]