SOAP Notes For Acupuncture Template

In a SOAP note, pain is documented primarily in the subjective section, where the patient describes their symptoms, including the location, intensity, and nature of their pain. This section captures the patient's personal experience and any changes since their last visit.

Documenting acupuncture involves detailing the treatment protocol in the objective section of the SOAP note, including specific acupuncture points used, techniques applied (e.g., needling, moxibustion), duration of treatment, and any immediate reactions observed. It’s also important to record the patient's response to treatment in subsequent visits.

To write effective acupuncture SOAP notes, follow the structured format: start with subjective, noting the patient's reported symptoms; then move to the objective, documenting findings like pulse and tongue diagnosis; next, provide an assessment that summarizes your clinical interpretation; and finally outline a plan that details the treatment approach, including selected points and any recommendations for follow-up care.