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10 Common Acupuncture SOAP Note Examples

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List of cases

  1. Chronic Back Pain
  2. Migraine Headaches
  3. Anxiety and Stress
  4. Insomnia
  5. Digestive Disorders
  6. Menstrual Pain
  7. Neck and Shoulder Tension
  8. Knee Osteoarthritis
  9. Allergies and Sinusitis
  10. Fibromyalgia

1. Chronic Back Pain

Description

The patient presents with chronic lower back pain affecting daily activities and sleep quality, seeking acupuncture treatment for pain management and improved mobility.

SOAP Note

Patient Name: Thomas Anderson

Date of Visit: 09/01/2024

Subjective

Thomas Anderson, a 45-year-old male, presents with chronic lower back pain persisting for 8 months. He describes the pain as dull and achy, rated 6/10, with occasional sharp sensations during movement. Pain worsens with prolonged sitting and early morning, improves with gentle movement. Reports difficulty with daily activities including bending and lifting. Previous treatments include physical therapy and NSAIDs with minimal relief. No radiating symptoms or numbness. Sleep is disturbed due to discomfort. Works as software developer, sitting 8-10 hours daily.

Objective

  • Vital Signs:
    • BP: 124/78 mmHg
    • HR: 72 bpm
    • RR: 16/min
  • Physical Examination:
    • Posture: Forward head posture, rounded shoulders
    • Palpation:
      • Tender points at BL 23, BL 25
      • Muscle tension in paraspinal muscles
    • Range of Motion:
      • Forward flexion limited to 60°
      • Extension limited to 15°
    • Tongue: Pale, thin white coating
    • Pulse: Wiry, deep

Assessment

  1. Chronic Lower Back Pain (ICD-10: M54.5)
    • Kidney Qi deficiency pattern
    • Local qi and blood stagnation
    • Affected channels: Bladder, Kidney
  2. Postural strain contributing to condition
  3. Work-related ergonomic factors

Plan

  1. Acupuncture Treatment:

    • Primary Points: BL 23, BL 25, GB 30, KI 3
    • Secondary Points: LI 4, LV 3
    • Method: Even technique, 25 minutes retention
    • Electroacupuncture: BL 23 to BL 25 bilateral

  2. Additional Modalities:

    • Cupping therapy to lower back
    • TDP lamp during treatment
    • Gua sha as needed

  3. Lifestyle Recommendations:

    • Ergonomic workspace assessment
    • Regular movement breaks
    • Gentle stretching exercises

  4. Follow-up:

    • Twice weekly for 4 weeks
    • Reassess after 8 treatments
    • Monitor pain levels and mobility

CPT Codes:

  • 97810 (Initial 15 minutes acupuncture)
  • 97811 (Additional 15 minutes acupuncture)
  • 97016 (Cupping therapy)

2. Migraine Headaches

Description

The patient presents with recurring migraine headaches, seeking acupuncture for pain relief and prevention of future episodes.

SOAP Note

Patient Name: Lisa Chen

Date of Visit: 09/02/2024

Subjective

Lisa Chen, a 35-year-old female, presents with chronic migraine headaches occurring 2-3 times monthly. Reports throbbing pain on right temple, rated 8/10, with associated nausea and photophobia. Triggers include stress, lack of sleep, and certain foods. Episodes typically last 24-48 hours. Currently taking sumatriptan as needed. Reports increased frequency of headaches in past month due to work stress. Seeks alternative treatment for prevention and management.

Objective

  • Vital Signs:
    • BP: 118/72 mmHg
    • HR: 76 bpm
    • RR: 14/min
  • Physical Examination:
    • Head/Neck:
      • Tender points at GB 20, TB 21
      • Tight suboccipital muscles
    • Face: Sensitivity around ST 8, GB 14
    • Tongue: Red sides, thin white coating
    • Pulse: Wiry, rapid

Assessment

  1. Chronic Migraine (ICD-10: G43.909)
    • Liver yang rising pattern
    • Liver qi stagnation
    • Affected channels: Gallbladder, Liver, Stomach

Plan

  1. Acupuncture Treatment:

    • Primary Points: GB 20, LI 4, LV 3, GB 8
    • Secondary Points: Yin Tang, ST 8
    • Method: Reducing technique, 30 minutes retention

  2. Additional Modalities:

    • Scalp acupuncture
    • Aromatherapy (lavender)
    • Ear seeds for maintenance

  3. Lifestyle Recommendations:

    • Stress management techniques
    • Sleep hygiene practices
    • Dietary modifications

  4. Follow-up:

    • Weekly treatments for 6 weeks
    • Monitor frequency and intensity
    • Keep headache diary

CPT Codes:

  • 97810 (Initial 15 minutes acupuncture)
  • 97811 (Additional 15 minutes acupuncture)

3. Anxiety and Stress

Description

The patient presents with anxiety and stress-related symptoms affecting daily life and sleep quality, seeking acupuncture for stress reduction and emotional balance.

SOAP Note

Patient Name: Emma Watson

Date of Visit: 09/03/2024

Subjective

Emma Watson, a 29-year-old female, presents with increasing anxiety and stress over the past 3 months. Reports frequent worry, racing thoughts, and difficulty relaxing. Experiences chest tightness, palpitations, and shallow breathing when stressed. Sleep is disrupted with difficulty falling asleep. Reports digestive issues including decreased appetite and occasional acid reflux. Works in high-pressure corporate environment. No current medications but uses chamomile tea for relaxation.

Objective

  • Vital Signs:
    • BP: 128/82 mmHg
    • HR: 88 bpm
    • RR: 18/min
  • Physical Examination:
    • Chest: Slight tension in upper chest
    • Abdomen: Mild epigastric tenderness
    • Tongue: Red tip, thin body, slight tremor
    • Pulse: Wiry, rapid

Assessment

  1. Generalized Anxiety (ICD-10: F41.1)
    • Heart and Spleen qi deficiency
    • Liver qi stagnation
    • Affected channels: Heart, Pericardium, Liver

Plan

  1. Acupuncture Treatment:

    • Primary Points: HT 7, PC 6, Yin Tang
    • Secondary Points: LV 3, SP 6, KI 6
    • Method: Calming technique, 30 minutes retention

  2. Additional Modalities:

    • Ear seeds for anxiety points
    • Aromatherapy (lavender, bergamot)
    • Breathing exercises during treatment

  3. Lifestyle Recommendations:

    • Meditation practice
    • Regular exercise routine
    • Stress management techniques

  4. Follow-up:

    • Weekly treatments for 6 weeks
    • Monitor anxiety levels
    • Track sleep patterns

CPT Codes:

  • 97810 (Initial 15 minutes acupuncture)
  • 97811 (Additional 15 minutes acupuncture)

4. Insomnia

Description

The patient presents with chronic insomnia, difficulty falling and staying asleep, seeking acupuncture for sleep regulation and relaxation.

SOAP Note

Patient Name: Robert Kim

Date of Visit: 09/04/2024

Subjective

Robert Kim, a 42-year-old male, presents with chronic insomnia persisting for 6 months. Reports taking 1-2 hours to fall asleep, with frequent night wakings. Averages 4-5 hours of sleep per night. Describes racing thoughts at bedtime and feeling "wired but tired." Reports daytime fatigue, irritability, and difficulty concentrating. Previously tried melatonin with minimal effect. Works evening shifts as emergency room nurse, variable schedule.

Objective

  • Vital Signs:
    • BP: 130/80 mmHg
    • HR: 82 bpm
    • RR: 16/min
  • Physical Examination:
    • Mental Status: Alert but fatigued
    • Tongue: Red body, no coating, small cracks
    • Pulse: Thin, rapid

Assessment

  1. Chronic Insomnia (ICD-10: G47.00)
    • Heart and Kidney yin deficiency
    • Liver fire rising
    • Affected channels: Heart, Kidney, Liver

Plan

  1. Acupuncture Treatment:

    • Primary Points: HT 7, KI 6, An Mian
    • Secondary Points: SP 6, PC 6, Yin Tang
    • Method: Sedating technique, 40 minutes retention

  2. Additional Modalities:

    • Ear seeds for insomnia points
    • Herbal sleep formula recommendation
    • Sound therapy during treatment

  3. Lifestyle Recommendations:

    • Sleep hygiene education
    • Evening relaxation routine
    • Screen time management

  4. Follow-up:

    • Twice weekly for 4 weeks
    • Keep sleep diary
    • Monitor daytime energy

CPT Codes:

  • 97810 (Initial 15 minutes acupuncture)
  • 97811 (Additional 15 minutes acupuncture)

5. Digestive Disorders

Description

The patient presents with chronic digestive issues including bloating, irregular bowel movements, and abdominal discomfort.

SOAP Note

Patient Name: Sarah Miller

Date of Visit: 09/05/2024

Subjective

Sarah Miller, a 38-year-old female, presents with chronic digestive issues including bloating, irregular bowel movements, and abdominal discomfort. Reports symptoms worsen with stress and certain foods. Bowel movements alternate between constipation and loose stools. Experiences post-prandial bloating and occasional acid reflux. Previous diagnosis of IBS. Currently avoiding dairy and gluten. Reports increased stress at work contributing to symptoms.

Objective

  • Vital Signs:
    • BP: 120/76 mmHg
    • HR: 74 bpm
    • RR: 16/min
  • Physical Examination:
    • Abdomen:
      • Tender at ST 25, CV 12
      • Mild distention
    • Tongue: Pale, scalloped edges, thick white coating
    • Pulse: Deep, weak

Assessment

  1. Irritable Bowel Syndrome (ICD-10: K58.9)
    • Spleen qi deficiency
    • Liver qi stagnation
    • Affected channels: Stomach, Spleen, Liver

Plan

  1. Acupuncture Treatment:

    • Primary Points: ST 36, SP 6, CV 12
    • Secondary Points: LI 4, LV 3, PC 6
    • Method: Tonifying technique, 30 minutes retention

  2. Additional Modalities:

    • Moxibustion on CV 12
    • Abdominal massage
    • Heat therapy

  3. Lifestyle Recommendations:

    • Food diary maintenance
    • Stress reduction techniques
    • Regular meal schedule

  4. Follow-up:

    • Weekly treatments for 8 weeks
    • Monitor symptom patterns
    • Track dietary triggers

CPT Codes:

  • 97810 (Initial 15 minutes acupuncture)
  • 97811 (Additional 15 minutes acupuncture)
  • 97014 (Electrical stimulation)

6. Menstrual Pain

Description

The patient presents with severe menstrual pain and associated symptoms, seeking acupuncture for pain management and cycle regulation.

SOAP Note

Patient Name: Jessica Park

Date of Visit: 09/06/2024

Subjective

Jessica Park, a 31-year-old female, presents with severe menstrual pain occurring monthly. Reports cramping pain rated 8/10, starting 1-2 days before menstruation. Associated symptoms include lower back pain, breast tenderness, and mood changes. Pain interferes with work and daily activities. Currently using over-the-counter pain medication with partial relief. Cycle length varies between 26-32 days. Heavy flow first 2-3 days with occasional clots.

Objective

  • Vital Signs:
    • BP: 116/74 mmHg
    • HR: 78 bpm
    • RR: 16/min
  • Physical Examination:
    • Abdomen: Tender at CV 4, SP 10
    • Lower Back: Sensitivity at BL 23
    • Tongue: Purple sides, thin white coating
    • Pulse: Wiry, deep

Assessment

  1. Primary Dysmenorrhea (ICD-10: N94.6)
    • Blood stagnation
    • Liver qi stagnation
    • Affected channels: Liver, Spleen, Conception Vessel

Plan

  1. Acupuncture Treatment:

    • Primary Points: SP 6, SP 8, CV 4
    • Secondary Points: LV 3, BL 23, ST 36
    • Method: Moving technique, 30 minutes retention

  2. Additional Modalities:

    • Moxibustion on lower abdomen
    • Heat therapy
    • Cupping on lower back

  3. Lifestyle Recommendations:

    • Regular exercise
    • Dietary modifications
    • Stress management

  4. Follow-up:

    • Weekly treatments
    • Track cycle and symptoms
    • Pre-emptive treatment before next cycle

CPT Codes:

  • 97810 (Initial 15 minutes acupuncture)
  • 97811 (Additional 15 minutes acupuncture)
  • 97016 (Cupping therapy)

7. Neck and Shoulder Tension

Description

The patient presents with chronic neck and shoulder tension related to computer work, seeking acupuncture for pain relief and muscle relaxation.

SOAP Note

Patient Name: David Wilson

Date of Visit: 09/07/2024

Subjective

David Wilson, a 36-year-old male, presents with chronic neck and shoulder tension persisting for 4 months. Reports constant tightness and occasional sharp pain, rated 5/10, worse at end of workday. Symptoms exacerbated by prolonged computer use and stress. Reports limited neck rotation and frequent tension headaches. Works as graphic designer, 8-10 hours daily at computer. Previous massage therapy provided temporary relief. No radiating symptoms or numbness in arms.

Objective

  • Vital Signs:
    • BP: 126/78 mmHg
    • HR: 74 bpm
    • RR: 16/min
  • Physical Examination:
    • Neck ROM:
      • Rotation restricted 20% bilaterally
      • Extension limited with pain
    • Palpation:
      • Tender points at GB 21, SI 11
      • Tight upper trapezius muscles
    • Tongue: Normal with slight red edges
    • Pulse: Wiry

Assessment

  1. Cervicalgia (ICD-10: M54.2)
    • Qi and Blood stagnation in channels
    • Liver qi stagnation
    • Affected channels: Gallbladder, Small Intestine, Triple Burner

Plan

  1. Acupuncture Treatment:

    • Primary Points: GB 21, SI 11, TB 15
    • Secondary Points: LI 4, LV 3
    • Method: Reducing technique, 25 minutes retention

  2. Additional Modalities:

    • Cupping therapy on upper back
    • Gua sha as needed
    • TDP lamp during treatment

  3. Lifestyle Recommendations:

    • Workstation ergonomic assessment
    • Neck stretches every 2 hours
    • Stress management techniques

  4. Follow-up:

    • Twice weekly for 3 weeks
    • Monitor ROM improvements
    • Track headache frequency

CPT Codes:

  • 97810 (Initial 15 minutes acupuncture)
  • 97811 (Additional 15 minutes acupuncture)
  • 97016 (Cupping therapy)

8. Knee Osteoarthritis

Description

The patient presents with bilateral knee osteoarthritis, seeking acupuncture for pain management and improved mobility.

SOAP Note

Patient Name: Margaret Thompson

Date of Visit: 09/08/2024

Subjective

Margaret Thompson, a 65-year-old female, presents with bilateral knee pain, right worse than left. Reports pain rated 7/10, worse with stairs and after sitting. Morning stiffness lasting 30 minutes. Previous cortisone injections with temporary relief. Currently using NSAIDs as needed. Reports difficulty with gardening and daily walks. X-ray confirmed moderate osteoarthritis 6 months ago.

Objective

  • Vital Signs:
    • BP: 132/78 mmHg
    • HR: 76 bpm
    • RR: 16/min
  • Physical Examination:
    • Knee ROM:
      • Right: 10-110 degrees with pain
      • Left: 5-120 degrees with mild pain
    • Palpation:
      • Tender at ST 35, SP 10
      • Mild effusion right knee
    • Tongue: Pale, slightly purple
    • Pulse: Deep, wiry

Assessment

  1. Bilateral Knee Osteoarthritis (ICD-10: M17.0)
    • Kidney yang deficiency
    • Local qi and blood stagnation
    • Affected channels: Stomach, Spleen, Kidney

Plan

  1. Acupuncture Treatment:

    • Primary Points: ST 35, SP 10, KI 3
    • Secondary Points: ST 36, SP 6
    • Method: Warming technique, 30 minutes retention

  2. Additional Modalities:

    • Moxibustion on affected points
    • Electrical stimulation
    • Heat therapy

  3. Lifestyle Recommendations:

    • Low-impact exercises
    • Weight management
    • Joint protection techniques

  4. Follow-up:

    • Twice weekly for 6 weeks
    • Monitor pain levels
    • Track activity tolerance

CPT Codes:

  • 97810 (Initial 15 minutes acupuncture)
  • 97811 (Additional 15 minutes acupuncture)
  • 97014 (Electrical stimulation)

9. Allergies and Sinusitis

Description

The patient presents with seasonal allergies and chronic sinusitis, seeking acupuncture for symptom relief and immune system support.

SOAP Note

Patient Name: Michael Brooks

Date of Visit: 09/09/2024

Subjective

Michael Brooks, a 33-year-old male, presents with seasonal allergies and recurring sinusitis. Reports nasal congestion, post-nasal drip, and frontal headaches. Symptoms worse in morning and during pollen season. Currently using over-the-counter antihistamines with partial relief. Reports fatigue and decreased sense of smell. Previous courses of antibiotics for sinusitis, last episode 2 months ago.

Objective

  • Vital Signs:
    • BP: 120/74 mmHg
    • HR: 72 bpm
    • RR: 16/min
  • Physical Examination:
    • Sinus: Tender frontal and maxillary areas
    • Nose: Pale, swollen turbinates
    • Throat: Mild post-nasal drainage
    • Tongue: Pale, thin white coating
    • Pulse: Floating, weak

Assessment

  1. Allergic Rhinitis with Sinusitis (ICD-10: J30.9)
    • Lung and Spleen qi deficiency
    • Wind-Cold invasion
    • Affected channels: Lung, Large Intestine, Stomach

Plan

  1. Acupuncture Treatment:

    • Primary Points: LI 20, ST 2, LI 4
    • Secondary Points: LU 7, ST 36
    • Method: Clearing technique, 25 minutes retention

  2. Additional Modalities:

    • Herbal sinus steam
    • Nasal acupressure
    • Dietary recommendations

  3. Lifestyle Recommendations:

    • Air purifier use
    • Nasal irrigation
    • Trigger avoidance

  4. Follow-up:

    • Weekly treatments during allergy season
    • Monitor symptom frequency
    • Track medication usage

CPT Codes:

  • 97810 (Initial 15 minutes acupuncture)
  • 97811 (Additional 15 minutes acupuncture)

10. Fibromyalgia

Description

The patient presents with fibromyalgia symptoms including widespread pain, fatigue, and sleep disturbances.

SOAP Note

Patient Name: Patricia Martinez

Date of Visit: 09/10/2024

Subjective

Patricia Martinez, a 48-year-old female, presents with widespread muscle pain and fatigue diagnosed as fibromyalgia 2 years ago. Reports pain intensity varying between 4-8/10, worse with weather changes and stress. Experiences sleep disturbances, morning stiffness, and "brain fog." Currently taking duloxetine with partial relief. Reports increased symptoms following recent job change. Multiple tender points affect daily activities and work performance.

Objective

  • Vital Signs:
    • BP: 118/72 mmHg
    • HR: 78 bpm
    • RR: 16/min
  • Physical Examination:
    • Tender Points: Multiple classic fibromyalgia points
    • Muscle Strength: 5/5 all extremities
    • ROM: Full but with pain
    • Tongue: Pale, slightly purple edges
    • Pulse: Thin, wiry

Assessment

  1. Fibromyalgia (ICD-10: M79.7)
    • Liver and Kidney qi deficiency
    • Blood stagnation
    • Affected channels: Multiple

Plan

  1. Acupuncture Treatment:

    • Primary Points: LI 4, LV 3, ST 36
    • Secondary Points: SP 6, KI 3, GB 34
    • Method: Gentle technique, 30 minutes retention

  2. Additional Modalities:

    • Gentle cupping
    • TDP lamp therapy
    • Auricular points

  3. Lifestyle Recommendations:

    • Gentle exercise program
    • Sleep hygiene
    • Stress management

  4. Follow-up:

    • Weekly treatments for 8 weeks
    • Monitor pain patterns
    • Track sleep quality

CPT Codes:

  • 97810 (Initial 15 minutes acupuncture)
  • 97811 (Additional 15 minutes acupuncture)
  • 97016 (Cupping therapy)

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