What they tell you.
Clinical SOAP Note Format
Subjective
– The “history” section HPI: include symptom dimensions, chronological narrative of
patient’s complains, information obtained from other sources (always identify source if not
the patient). Pertinent past medical history. Pertinent review of systems, for example,
“Patient has not had any stiffness or loss of motion of other joints.” Current medications
(list with daily dosages).
Objective
– The physical exam and laboratory data section Vital signs including oxygen saturation
when indicated. Focuses physical exam. All pertinent labs, x-rays, etc. completed at the
visit.
Facts that can be verified:
Vital signs, labs, swelling, discoloration, etc.
Outside notes information
Assessment/Problem List
– Your assessment of the patient’s problems
Assessment: A one sentence description of the patient and major problem
Problem list: A numerical list of problems identified All listed problems need to be
supported by findings in subjective and objective areas above. Try to take the assessment
of the major problem to the highest level of diagnosis that you can, for example, “low back
sprain caused by radiculitis involving left 5th LS nerve root.” Provide at least 2 differential
diagnoses for the major new problem identified in your note.
East Asian Diagnosis/ Western
Plan – Your plan for the patient based on the problems you’ve identified Develop a diagnostic
and treatment plan for each differential diagnosis. Your diagnostic plan may include tests,
procedures, other laboratory studies, consultations, etc. Your treatment plan should
include: patient education, pharmacotherapy if any, other therapeutic procedures. You
must also address plans for follow-up (next scheduled visit, etc.). Also see your Bates Guide
to Physical Examination for excellent examples of complete H & P and SOAP note formats.
Acupuncture – with points used for treatment listed, Ashii points with or without e-stim
Accessory techniques preformed/location of techniques used: Tuina, cupping, gausha etc. if
oils or liniments used
Number of treatments planned before reevaluation
Education information- qi gong. Diet, meditation, sleep suggestions, herbals or
supplementation
https://owl.purdue.edu/owl/subject_specific_writing/healthcare_writing/soap_notes/major_sections.html
Name and MR# ___________ or Unique clinic ID# ______
Procedure: Intake and Acupuncture treatment
Today’s date: 8/14/2020
All correct equipment/supplies are present and ready for use prior to the procedure.
YES
Patient stated name and date of birth with a picture ID.
Yes -DOB 6/14/1972 - NAME: Jane Doe
Patient verbally stated the procedure (including the site and side) to be completed.
YES
Informed Consent reviewed and consistent with procedure.
YES
SUBJECTIVE: Jane Doe is a 48year old Female was referred to XXXX Department by PCP (Dr. Marcy Jones) and a copy of the
report will be sent to that provider by electronic medical record.
This patient was sent for evaluation for acupuncture treatments for chronic low back pain and will perform intake face to face and
acupuncture treatment #1 under their benefit year effective date Jan 1, 2020.
Ms. Doe reports she has never had acupuncture, or dry needling, but does see a chiropractor weekly for her chronic low back pain with
only slight benefit to her pain she says it helps her with mood.
Presenting complaint/Prior Diagnosis: SPINAL STENOSIS OF LUMBAR SPINE, HEADACHES, and ANXIETY
Pain score (1-10) Pain score and area: B- LBP with sciatica, worse on right side, running down right buttock down UB channel to
right lateral ankle reports the pain is 6/10 and jumps up when she first gets up in morning and has been ongoing since 2018 when she
reports he had a bike accident. She reports monthly frontal headaches that come on a day before her mensuration flow starts but she
does not have one today.
Allergies: NKA
Medications: Meloxican(Mobic)15mg 1tablet PO daily, Pregablin(Lyrica)50mg 1tablet PO daily, Fluoxetine(Prozac)20mg PO daily
Ms. Doe reports last eating: 11:00am
Heat/Cold
Ms Doe reports her temperature is about the same as those around her. When she has pain
she uses
a heating pad.
Perspiration
She reports she sweats about the same as those around them.
Body pain area
Do patient have any head or body pain. If body pain what location(s). And what side. B-
LBP with sciatica, worse on right side, running down right buttock down UB channel to
right lateral ankle reports the pain is 6/10 and jumps up when she first gets up in morning.
She reports monthly frontal headaches that come on a day before her mensu
ration flow
starts.
She reports no abdominal pain or other digestive issues.
Hunger
When it comes to hunger when is patient – she reports that she only eats because they know
they should just at a mealtime.
Thirst
She reports she only drinks because she knows they should.
Temp of liquids
Her temperature preference for what she drinks is cold too cold with ice cubes.
Urination
She reports her frequency of urine more than 5times a day
Stool
She reports she has daily to 2 times daily - Bowel movements. daily or less often, with
more formed stools
Vision
She reports she wears her glasses and if so do they wear them - all the time
Hearing
She reports she has ringing in the ears- like whistle and has decreased hearing on the right
side.
Sleep
She reports she has difficulty falling asleep, staying asleep, and difficulty falling back to
sleep once awoken, and she only hours a night do they sleep total 6.5hours including naps.
Reproductive:
When it comes to reproduction/intercourse is the patient - Still sexually active, but her
p
artner medical issues that limit their frequency. She reports still having regular periods.
LMP: 7/28/2020
Constitution:
She reports she is working as a OR nurse for Nursing temp agency
Jane Doe MR#5551212
Objective:
Vitals: BP:135/77, P:59, Temp 97.9F, Resp: 16, Ht: 5’5”, Wt: 108lb 4.8oz, LMP: 7/28/2020
Tongue: slight red tip, slight center crack, thin coat, darker pink tongue
Radial Pulse Right: wiry, slippery, moderate
Radial Pulse Left: wiry, slippery, moderate
Assessment/Problem List:
East Asian Diagnosis(TCM):
Root:(causes) KD/SP QI def
Branch:(acute issues) wind cold bi
Treatment Strategy: nourish kd/sp qi and release wind cold bi
Plan:
Acupuncture: Treatment with patient facedown (Prone): Right unilateral treatment: UB40, UB57, UB60, KD7, PC6, TW5, UB24,
UB23, UB22, ST36, GB34, LI11, LI4, (B)GB20, DU15, ANIMEN,
Ear points (B)Shenman, Liver, Upper Lung, Kidney, Sympathetic
Needle count
Seirin
Green 6
Red 6
DBC
18x30 10
Totals 22
Sign: Dr. NCCAOM LAC
Needles removed# 22
Removed and Needle count verified by staff.
Intake and acupuncture treatment today
Four everyother week acupuncture treatments and then reevaluate at 5th visit and make new plan with adjustments if needed.
Education
Diet suggestions given
Exercises given
Neck protection suggested
Qi Gong Breathing Taught
Verbal consent for today's treatment, sign consent on file. verbalized understanding of the consent and had an opportunity to
have all questions answered. Risks and potential complications related to acupuncture procedures were explained to patient
and understanding was verbalized.
Prior to the treatment the possible complications of acupuncture were again reviewed as were the areas of the patient’s pain and
expectations of treatment.
Technique: Area identified. Acupuncture performed in typical manner.
Patient tolerated procedure well without difficulty. The treatment time was 20min discussion and education and 20 minutes needles
placed.
Pain score(1-10) Post treatment: Dr Doe reports, “Wow! My pain is gone now!” and she will observe for pain relief score and will
report back at next visit.
Dr. NCCAOM LAC
Clinic Address
Phone
Resources
https://owl.purdue.edu/owl/subject_specific_writing/healthcare_writing/soap_notes/major_sections.html
Baird, Brian N. (2014). The internship, practicum, and field placement handbook. 7th Ed. New York: Routledge.
Cameron, Susan & turtle-song, imani. (2002). Learning to write case notes using the SOAP format. Journal of Counseling &
Development, 80, 286-292.
Heifferon, Barbara A. (2005). Writing in the health professions. New York: Pearson/Longman.
Kettenbach, Ginge. (2009). Writing patient and client reports: Ensuring accuracy in documentation. 4thEd. F.A. Davic Co.
Moline, Mary E., & Borcherding, Sherry. (2013). The OTA’s guide to documentation: Writing SOAP notes. 3rd Ed. Thornfield, NJ:
Slack Inc.
Moline, Mary E., Williams, George T., & Austin, Kenneth M. (1998). Documenting psychotherapy: Essentials for mental health
practitioners. Thousand Oaks, CA: Sage.
Sullivan, Debra D. (2011). Guide to clinical documentation. 2nd Ed. F.A. Davis Company.
