SOAP Note Example
Acupuncture SOAP Note Example
Below is a complete SOAP note example for an acupuncture session treating chronic migraine headaches with a TCM pattern of Liver Qi Stagnation with Liver Yang Rising. This example shows how to bridge TCM diagnosis with Western-style documentation.
Complete Acupuncture SOAP Note
SUBJECTIVE:
Patient presents for acupuncture treatment of chronic migraine headaches, occurring 3-4 times per week for the past 6 months. Current headache rated 5/10, located at the temples and behind the eyes, described as throbbing. Reports headaches are worse during menstruation and periods of high stress. Associated symptoms: irritability, premenstrual breast distention, difficulty falling asleep with racing thoughts, and occasional night sweats. Digestion is generally normal with bloating after meals. Afternoon energy dip around 3-4 PM. Prefers warm drinks. This is the patient's 3rd acupuncture treatment. Reports headache frequency has decreased from 4 to 2 episodes per week since starting care.
OBJECTIVE:
Tongue: slightly red body with redder sides, thin white coating, slight dryness. Scalloping at edges. Pulse: wiry bilaterally, thin, slightly rapid. Left guan position is notably wiry. Palpation: tenderness at GB20, GB21, and Taiyang bilateral. Ashi points noted at bilateral upper trapezius. TCM Pattern Differentiation: Liver Qi Stagnation with ascending Liver Yang, underlying Blood and Yin Deficiency. Points needled: GB20 (bilateral), GB21 (bilateral), Taiyang (bilateral), LI4 (bilateral), LV3 (bilateral — Four Gates), SP6 (bilateral), GV20, Yintang, Ear Shenmen (bilateral), Ear Liver point (bilateral). All points needled with 0.25x30mm filiform needles, depth appropriate to location. De qi achieved at all body points. Needle retention: 25 minutes. Infrared TDP heat lamp applied to lower abdomen during retention. Auricular press seeds placed at Shenmen and Liver points bilateral for between-treatment stimulation.
ASSESSMENT:
TCM diagnosis: Liver Qi Stagnation with Liver Yang Rising, underlying Blood and Yin Deficiency. The wiry-thin pulse, red-sided tongue, temporal/retro-orbital headache pattern, emotional symptoms (irritability), menstrual aggravation, and sleep disturbance are consistent with this pattern. Patient showed significant relaxation during needle retention. Headache intensity decreased from 5/10 to 1/10 post-treatment. Reduction in headache frequency from 4 to 2 episodes per week over 3 treatments indicates positive response to care. Treatment plan is progressing as expected.
PLAN:
Continue weekly acupuncture for 6 more sessions (9 total), reassess at session 9. Maintain current point prescription with modifications as pattern evolves. Dietary recommendations reinforced: reduce coffee to 1 cup before noon (caffeine aggravates Liver Yang), minimize alcohol and spicy foods, increase dark leafy greens and blood-nourishing foods (beets, black sesame, goji berries, dates). Lifestyle: 10 minutes of diaphragmatic breathing before bed to support sleep and calm Liver Qi. Gentle movement recommended — walking or yin yoga. Herbal formula discussion: Xiao Yao San (Free and Easy Wanderer) modified with Gou Teng and Tian Ma — patient expressed interest, will bring formula details and pricing to next visit. Patient to maintain headache diary with triggers, frequency, and intensity. Next session in 1 week.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
Include both the Western chief complaint and TCM-relevant intake information (sleep, digestion, energy, emotions, temperature preferences). Note progress since starting treatment with specific numbers (4 episodes → 2 episodes). This data supports continued care.
Objective
Tongue and pulse documentation is essential in acupuncture notes — these are your primary diagnostic tools. List all points needled with bilateral notation. Document needle specifications, retention time, de qi, and any additional modalities. This demonstrates skilled treatment and supports insurance billing.
Assessment
State the TCM pattern diagnosis clearly and explain how your findings support it. Include the Western clinical correlation when possible. Document treatment response with measurable data (pain scale change, frequency reduction) to show the treatment is working.
Plan
Include treatment frequency and review timeline. TCM-specific dietary and lifestyle recommendations show whole-person treatment. Document herbal recommendations with the formula name. A headache diary helps gather better data for future sessions.
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