Acupuncture: Step-by-Step Guide on How to Write SOAP Notes

SOAP notes are essential for effective patient care and documentation in acupuncture. This guide provides detailed instructions for each section of a SOAP note, helping you understand the structure and content required for thorough documentation in the acupuncture context. By mastering SOAP notes, you can enhance patient care, ensure effective communication among healthcare providers, and maintain accurate medical records.

Generate Your Acupuncture SOAP Note in just 2 minutes

First 3 SOAP Notes are free

Try Now

Subjective Section (S)

In an acupuncture SOAP note, the Subjective section (S) captures the patient’s self-reported information about their condition and symptoms. This section provides context for the acupuncturist to understand the patient’s perspective and experiences. Here are the specific things that should go into the Subjective section of an acupuncture SOAP note:

Subjective Section (S) Components

1. Chief Complaint:

   • The primary reason the patient is seeking acupuncture treatment.
   • Example: "I have been experiencing chronic migraines for the past three months."

2. History of Present Illness/Condition:

   • Details about the onset, duration, and progression of the current condition.
   • Description of how and when the symptoms began.
   • Example: "The migraines started gradually and have become more frequent and severe over the past three months."

3. Pain Description:

   • Location, intensity, quality, and duration of the pain or discomfort.
   • Pain scale rating (e.g., 0-10 scale).
   • Example: "The patient reports a throbbing pain in the temples, rated as 8/10."

4. Functional Limitations:

   • Impact of the condition on daily activities and functions.
   • Specific tasks or activities that are difficult or impossible due to the condition.
   • Example: "The patient has difficulty concentrating at work and experiences nausea during migraines."

5. Previous Treatments and Outcomes:

   • Information on any treatments the patient has previously received for the condition.
   • The effectiveness or outcome of those treatments.
   • Example: "The patient has tried prescription medications, which provided temporary relief but caused side effects."

6. Relevant Medical History:

   • Any relevant past medical conditions, surgeries, or injuries.
   • Family history if applicable to the condition.
   • Example: "The patient has a history of tension headaches and a family history of migraines."

7. Medications:

   • Current medications the patient is taking, including dosage and frequency.
   • Any recent changes in medication.
   • Example: "The patient is currently taking sumatriptan as needed for migraines."

8. Patient Goals:

   • The patient’s goals and expectations from acupuncture treatment.
   • Example: "The patient hopes to reduce the frequency and severity of migraines."

9. Other Relevant Information:

   • Any other information provided by the patient that may be relevant to their treatment.
   • Example: "The patient reports increased stress at work, which seems to trigger migraines."

Tips:

• Use the patient’s own words when possible.
• Be thorough in capturing all relevant details.
• Ask open-ended questions to gather comprehensive information.

Example of a Subjective Section for Acupuncture

Objective Section (O)

In an acupuncture SOAP note, the Objective section (O) captures measurable, observable, and factual data obtained during the patient’s examination. This section provides concrete evidence of the patient’s condition and progress. Here are the specific things that should go into the Objective section of an acupuncture SOAP note:

Objective Section (O) Components

1. Observation:

   • Document any visible signs or symptoms observed during the examination.
   • Example: "The patient appears fatigued and has dark circles under the eyes."

2. Palpation:

   • Findings from palpation, including areas of tenderness, tension, or abnormalities.
   • Example: "Tenderness noted in the temples and neck muscles."

3. Tongue Diagnosis:

   • Description of the tongue's appearance, including color, coating, and shape.
   • Example: "The tongue is pale with a thin white coating."

4. Pulse Diagnosis:

   • Findings from pulse palpation, including rate, rhythm, and quality.
   • Example: "The pulse is wiry and rapid."

5. Range of Motion (ROM):

   • Measure and record the range of motion for relevant joints or body parts if applicable.
   • Example: "Limited range of motion in the neck."

6. Functional Tests:

   • Record the results of any functional tests performed, such as balance tests or functional movement screenings.
   • Example: "Balance test shows slight instability when standing on one leg."

7. Diagnostic Tests:

   • Include results of any diagnostic tests relevant to the acupuncture session, such as imaging reports or lab results.
   • Example: "MRI shows no structural abnormalities in the brain."

Tips:

• Be precise and factual in your documentation.
• Include only measurable and observable data.
• Use standardized scales and measurements where applicable.

Example of an Objective Section for Acupuncture

Assessment Section (A)

In an acupuncture SOAP note, the Assessment section (A) synthesizes the information gathered in the Subjective and Objective sections to provide a clinical judgment about the patient’s condition. This section includes the acupuncturist's professional interpretation, diagnosis, and the patient’s progress and response to treatment. Here are the specific things that should go into the Assessment section of an acupuncture SOAP note:

Assessment Section (A) Components

1. Diagnosis:

   • Provide a clinical diagnosis based on the subjective and objective findings.
   • Example: "Chronic migraines with associated tension-type headaches."

2. Clinical Impression:

   • Include your clinical interpretation of the patient’s condition.
   • Example: "The patient’s symptoms are consistent with chronic migraines, likely exacerbated by stress and tension."

3. Functional Limitations:

   • Document the impact of the patient’s condition on their daily activities and functional abilities.
   • Example: "The patient has significant limitations in concentration and experiences nausea during migraines."

4. Patient Progress:

   • Comment on the patient’s progress since the last visit, if applicable.
   • Example: "Since the last visit, the patient reports a slight reduction in migraine frequency but continues to experience severe pain."

5. Prognosis:

   • Provide an outlook on the patient’s recovery based on their condition and response to treatment.
   • Example: "With continued acupuncture treatment, the patient has a good prognosis for reducing migraine frequency and severity."

6. Goals:

   • Set specific, measurable, achievable, relevant, and time-bound (SMART) goals for the patient’s treatment.
   • Example: "Short-term goal: Reduce migraine frequency to once a week within one month. Long-term goal: Eliminate migraines and associated symptoms within three months."

Tips:

• Be clear and concise in your clinical judgment.
• Use evidence-based reasoning to support your diagnosis and clinical impression.
• Set realistic and measurable goals for the patient.

Example of an Assessment Section for Acupuncture

Plan Section (P)

Plan Section (P) Components

1. Treatment Plan:

   • Specific interventions that will be implemented to address the patient’s condition.
   • Example: "Acupuncture treatment focusing on points LI4, GB20, and ST36."

2. Herbal Medicine:

   • Any herbal remedies prescribed, including dosage and frequency.
   • Example: "Prescribe Xiao Yao San, 3 grams twice daily."

3. Lifestyle and Dietary Recommendations:

   • Advice on lifestyle changes and dietary modifications to support treatment.
   • Example: "Recommend stress reduction techniques such as meditation and a diet rich in anti-inflammatory foods."

4. Patient Education:

   • Information and instructions provided to the patient to help them manage their condition and prevent further issues.
   • Example: "Educate the patient on identifying and avoiding migraine triggers."

5. Home Care Instructions:

   • Exercises or activities prescribed for the patient to perform at home between sessions.
   • Example: "Recommend daily neck stretches and relaxation exercises."

6. Referral:

   • Any referrals to other healthcare professionals or specialists if necessary.
   • Example: "Refer the patient to a neurologist for further evaluation if no improvement is seen in six weeks."

7. Follow-Up:

   • The plan for subsequent visits, including the frequency and duration of follow-up appointments.
   • Example: "Schedule follow-up appointments once a week for the next six weeks to monitor progress and adjust the treatment plan as necessary."

Tips:

• Be specific and detailed in your treatment plan to ensure clarity and adherence.
• Tailor the plan to the individual needs and goals of the patient.
• Ensure that the patient understands their role in the treatment plan, especially for home care and self-care.

Example of a Plan Section for Acupuncture

This detailed information in the Plan section ensures that the patient receives a comprehensive and personalized treatment strategy, and helps track progress and outcomes effectively.