SOAP Note Example
Naturopathy SOAP Note Example
Below is a complete SOAP note example for a naturopathic medicine visit addressing chronic fatigue and digestive complaints. This example demonstrates proper documentation of a whole-person assessment including dietary history, lifestyle factors, laboratory evaluation, and an integrative treatment plan combining botanical medicine, nutritional supplementation, and lifestyle modification.
Complete Naturopathy Note
SUBJECTIVE:
Patient is a 38-year-old female presenting with persistent fatigue and bloating of approximately 6 months duration. Reports energy levels are consistently low throughout the day, rating fatigue severity as 7/10, with the worst period occurring between 2-4 PM. Describes abdominal bloating that worsens after meals, particularly after consuming wheat-based foods and dairy products. Associated symptoms include intermittent loose stools (2-3 episodes per week), brain fog, and difficulty concentrating at work. Sleep: reports sleeping 7-8 hours per night but waking feeling unrefreshed; wakes 1-2 times per night without identifiable cause. Stress: reports high occupational stress as a project manager; rates overall stress level 8/10. Diet: primarily convenience foods, limited vegetable intake (1-2 servings per day), consumes 3 cups of coffee daily to manage fatigue, water intake approximately 4 glasses per day. Exercise: sedentary lifestyle, no regular physical activity for the past year due to fatigue. Previous evaluation: PCP ran basic labs 3 months ago — CBC and TSH reported as normal (patient does not have copies). Tried an over-the-counter probiotic for 2 weeks with no noticeable improvement. No current medications. Supplements: multivitamin (inconsistent use). No known drug allergies. No significant past medical history. Family history: mother with Hashimoto thyroiditis, maternal aunt with celiac disease.
OBJECTIVE:
Vital signs: BP 108/68, HR 72, Temp 98.4°F, Weight 142 lbs, Height 5'6", BMI 22.9. General appearance: well-nourished female appearing fatigued with dark circles under the eyes. Skin: mildly dry, particularly on the elbows and shins; no rashes or lesions. Nails: mild vertical ridging bilaterally. Tongue assessment: pale, slightly swollen with scalloped edges and a thin white coating. Abdominal exam: soft, non-distended at rest; mild diffuse tenderness to deep palpation in the periumbilical region; no organomegaly, masses, or rebound tenderness; hyperactive bowel sounds in all four quadrants. Thyroid: non-enlarged, no palpable nodules, non-tender. Laboratory results (ordered at initial intake visit 2 weeks ago, now reviewed): comprehensive metabolic panel within normal limits; CBC: WBC 5.8, RBC 4.1, Hgb 12.2 g/dL (low-normal), Hct 36.8%, MCV 89.8 fL, ferritin 18 ng/mL (low, reference 20-200), vitamin B12 310 pg/mL (low-normal, reference 200-900), 25-OH vitamin D 22 ng/mL (insufficient, reference 30-100), TSH 3.8 mIU/L (within standard range but suboptimal for symptom profile), free T4 1.1 ng/dL (normal), free T3 2.4 pg/mL (low-normal, reference 2.3-4.2), TPO antibodies 48 IU/mL (mildly elevated, reference <35), fasting glucose 88 mg/dL, HbA1c 5.2%. Food sensitivity panel (IgG): elevated reactivity to gluten, cow dairy (casein and whey), and eggs. Salivary cortisol (4-point): morning 18 nM (normal), noon 8 nM (normal), afternoon 3 nM (low, reference 4-8), evening 2 nM (normal). DUTCH dried urine hormone panel: cortisol metabolites on the lower end of normal range, DHEA mildly low for age.
ASSESSMENT:
Clinical presentation is consistent with early-stage Hashimoto thyroiditis with mildly elevated TPO antibodies and suboptimal thyroid conversion (low-normal free T3 relative to TSH), contributing to fatigue and brain fog. Laboratory findings also reveal iron deficiency without frank anemia (ferritin 18), vitamin D insufficiency (22 ng/mL), and low-normal B12 — all of which compound fatigue and impair immune regulation. Afternoon cortisol dip correlates with the patient's reported 2-4 PM energy crash, suggesting HPA axis dysregulation secondary to chronic stress. IgG food sensitivity results and digestive symptoms (bloating, loose stools after wheat and dairy) suggest intestinal hyperpermeability and food-mediated immune activation, which may be driving systemic inflammation and autoimmune thyroid activity. Family history of Hashimoto and celiac disease further supports a genetic predisposition to autoimmune and gluten-related conditions. The constellation of findings points to a multi-system pattern involving thyroid autoimmunity, nutrient depletion, gut-immune dysfunction, and HPA axis imbalance — all amenable to naturopathic intervention with monitoring.
PLAN:
Dietary modifications: implement a 6-week elimination diet removing gluten, cow dairy, and eggs with guided reintroduction protocol beginning week 7. Increase vegetable intake to minimum 5 servings per day emphasizing cruciferous vegetables (broccoli, cauliflower, Brussels sprouts) for thyroid-supportive indole-3-carbinol. Increase water intake to 64 oz per day. Reduce coffee to 1 cup before noon to support cortisol rhythm recovery. Supplementation: iron bisglycinate 36 mg daily with vitamin C 500 mg on an empty stomach (recheck ferritin in 90 days, goal >50 ng/mL); vitamin D3 5,000 IU daily with vitamin K2 100 mcg (recheck 25-OH-D in 90 days, goal 50-70 ng/mL); methylcobalamin (B12) 1,000 mcg sublingual daily; selenium 200 mcg daily (selenomethionine form) for TPO antibody reduction; magnesium glycinate 400 mg at bedtime for sleep quality and stress support. Botanical medicine: ashwagandha (Withania somnifera) standardized root extract 600 mg daily in divided doses for HPA axis support and thyroid modulation; gut repair protocol — L-glutamine 5 g daily, deglycyrrhizinated licorice (DGL) 400 mg before meals, and a multi-strain probiotic (Lactobacillus and Bifidobacterium species, 50 billion CFU) daily. Lifestyle: 20-minute daily walk to begin, increasing to 30 minutes over 4 weeks; 10-minute guided meditation or deep breathing daily for stress management; sleep hygiene counseling — consistent bedtime by 10:30 PM, no screens 1 hour before bed. Follow-up: return in 6 weeks for symptom reassessment, dietary compliance review, and to plan reintroduction phase. Recheck ferritin, vitamin D, B12, TSH, free T3, and TPO antibodies at 90 days. If TPO antibodies remain elevated or free T3 does not improve, consider further thyroid support including myoinositol and referral for thyroid ultrasound. Patient counseled on the rationale for each recommendation and verbalized understanding.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
The naturopathic subjective section requires a thorough whole-person intake that goes beyond the chief complaint. Document energy patterns throughout the day, digestive symptoms with specific triggers, sleep quality (not just duration), stress levels, and detailed dietary and lifestyle habits — these are foundational to naturopathic assessment. Include family history of autoimmune conditions as this directly influences clinical suspicion and testing decisions. Note previous conventional workups and their results (or lack thereof) to demonstrate coordination of care and avoid redundant testing.
Objective
Naturopathic objective documentation combines conventional physical examination findings with assessments unique to naturopathic practice such as tongue and nail evaluation. Report laboratory results with reference ranges and clinical interpretation — noting where values fall within the 'normal' range matters in naturopathic practice because optimal ranges often differ from standard lab reference ranges (e.g., ferritin of 18 is technically normal but functionally deficient). Include specialty testing such as food sensitivity panels, salivary cortisol, and hormone metabolite panels with clear documentation of the clinical rationale for ordering them.
Assessment
The naturopathic assessment should weave together multiple findings into a coherent clinical narrative that identifies root causes rather than simply labeling symptoms. Connect the dots between systems — in this case, linking thyroid autoimmunity, nutrient deficiency, gut dysfunction, and HPA axis imbalance into a unified clinical picture. Reference the family history and genetic predisposition to support your clinical reasoning. This systems-based assessment distinguishes naturopathic documentation from conventional notes and justifies the multi-modal treatment approach that follows.
Plan
Naturopathic treatment plans are typically multi-faceted, addressing diet, supplementation, botanical medicine, and lifestyle simultaneously. Document each recommendation with specific dosages, forms (iron bisglycinate vs. ferrous sulfate matters), timing, and duration. Include measurable goals and timelines for reassessment (e.g., recheck ferritin at 90 days, goal >50). The elimination diet should specify what is being removed, for how long, and when reintroduction begins. Botanical prescriptions should include the Latin binomial, standardization details, and the therapeutic rationale. This level of specificity demonstrates evidence-informed prescribing and allows any practitioner to continue the treatment plan.
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