Traditional Chinese Medicine Follow-Up SOAP Note (Acupuncture/Herbal Medicine)

Date: [date of service]

Patient: [patient name], [DOB]

Provider: [provider name and credentials]

Reason for Visit

[Primary concern and reason for return] (Limit to one or two concise lines.)

Subjective

[Interval history since last visit] (Describe patient-reported symptom changes since prior visit including direction [better/worse/same], severity with consistent measures such as 0–10 scales, functional impact, response to last treatment with immediate and sustained effects, any adverse effects from prior acupuncture or herbs, and patient's goals for today. Combine into a single coherent paragraph.)

[Current medications, supplements, and herbal formula use] (List only items relevant to safety or the presenting concerns; note anticoagulants if applicable. Include herbal formula adherence and tolerability if relevant.)

[Red flag screening findings] (Only include if the complaint warranted screening and it was actually performed; omit if not assessed.)

Objective

(Include only clinician-observed or measured findings from today. Do not copy forward prior findings.)

Tongue: [body color, shape, coat color/thickness, moisture, notable features] (If not assessed this visit, state "Not assessed this visit.")

Pulse: [rate, depth, strength, qualities, positions if cun/guan/chi assessed] (If not assessed this visit, state "Not assessed this visit.")

Exam/Vitals: [pertinent physical findings and vital signs] (Only include items actually assessed today.)

Assessment

[Brief clinical summary linking subjective and objective findings] (Summarize how current symptoms and exam findings relate; note changes since last visit.)

• TCM Pattern(s): [current pattern differentiation with key supporting evidence from tongue, pulse, and symptoms] (Note pattern changes since last visit.)
• Biomedical Diagnosis: [diagnosis or clinical impression with ICD-10 if required] (Include when relevant for coordination or billing.)
• Treatment Response: [improving / plateau / worsening] (Required when documenting ongoing care for conditions where continued treatment depends on demonstrated improvement.)

Plan

Treatment Today

• Acupuncture: [point selection with standardized names and laterality] (Include needle retention time, stimulation technique, and relevant details.)
• Adjunct therapies: [modality, location, parameters, duration] (Include electroacupuncture settings, moxibustion, cupping, gua sha, or other adjuncts as applicable.)
• Tolerance and response: [patient tolerance and immediate post-treatment response]
• Adverse events: [description and management] (Only include if any occurred.)

Herbal Medicine

• Formula: [formula name and form] (State if new, modified, or continued.)
• Modifications: [additions, subtractions, or ratio changes from prior prescription] (Only include if applicable.)
• Dosing: [dose, frequency, timing, administration instructions, and duration until reassessment]
• Safety: [contraindication review, interaction precautions, stop/contact instructions] (Document relevant safety considerations as applicable.)
• Adherence/tolerability: [patient report] (Include if continuing unchanged formula.)

Recommendations

[Diet, lifestyle, activity, self-care guidance, and home care instructions] (Only include items discussed today.)

Follow-Up

• Interval: [recommended return timeframe]
• Focus: [specific symptoms or functional goals to reassess]
• Return precautions: [reasons to contact clinic or seek urgent care] (Only include if clinically indicated.)

Consent: [confirmation of informed consent for new modality] (Only include if new modalities were initiated this visit.)

Signature: [electronic signature with credentials, date/time]