Free Template
SOAP Note Template for Acupuncture
Acupuncturists need documentation that bridges Traditional Chinese Medicine (TCM) pattern differentiation with Western clinical terminology. This template accommodates both TCM diagnosis and conventional SOAP formatting required by insurance companies.
Blank Acupuncture SOAP Note Template
Copy this template and fill in the bracketed sections with your session details.
SUBJECTIVE: Patient presents with [chief complaint]. [Duration and onset]. [Quality and location of symptoms]. [TCM intake: sleep, digestion, energy, emotional state, temperature preference]. [Relevant medical history]. OBJECTIVE: Tongue: [body color, shape, coating, moisture]. Pulse: [rate, quality — e.g., wiry, slippery, thin, deep]. Palpation: [ashi points, channel tenderness]. TCM Pattern: [pattern differentiation — e.g., Liver Qi Stagnation, Kidney Yin Deficiency]. Points needled: [list points with bilateral notation]. Needle retention: [X] minutes. Additional modalities: [moxa, cupping, e-stim, gua sha]. ASSESSMENT: [TCM diagnosis/pattern]. [Western clinical correlation if applicable]. [Response to treatment — de qi sensation, symptom change]. [Progress toward treatment goals]. PLAN: [Follow-up frequency]. [Dietary/lifestyle recommendations per TCM]. [Herbal formula if prescribed]. [Re-evaluation timeline].
Filled Example — Acupuncture
Here's what a completed SOAP note looks like for a acupuncture session.
SUBJECTIVE: Patient presents with chronic migraine headaches occurring 3-4 times per week for the past 6 months. Pain is described as throbbing, primarily at the temples and behind the eyes, rated 8/10 during episodes. Reports headaches are worse during menstruation and periods of high stress. Associated symptoms include irritability, PMS with breast distention, and disrupted sleep (difficulty falling asleep). Digestion is generally normal with occasional bloating after meals. Energy is low in the afternoon. Prefers warm drinks. Previous treatment with prescription triptans provides partial relief. OBJECTIVE: Tongue: slightly red body, thin white coating, slightly dry. Sides of tongue are slightly redder. Pulse: wiry and thin bilaterally, slightly rapid. Palpation reveals tenderness at GB20, GB21, Taiyang, and LI4 bilateral. TCM Pattern: Liver Qi Stagnation with rising Liver Yang and underlying Blood Deficiency. Points needled: GB20 (bilateral), GB21 (bilateral), Taiyang (bilateral), LI4 (bilateral), LV3 (bilateral), SP6 (bilateral), GV20, Yintang. Needle retention: 25 minutes. De qi achieved at all points. Infrared heat lamp applied to lower abdomen during treatment. Auricular seeds placed at Shenmen and Liver points bilateral. ASSESSMENT: TCM diagnosis: Liver Qi Stagnation with Liver Yang Rising and underlying Blood Deficiency. The wiry pulse, temporal headache pattern, stress/menstrual aggravation, and emotional symptoms are consistent with this pattern. Patient reported significant relaxation during treatment. Headache intensity reduced from 5/10 (present today) to 2/10 post-treatment. This is the patient's third treatment; reports headache frequency has decreased from 4 to 2 episodes per week since starting care. PLAN: Continue weekly acupuncture treatments for the next 6 weeks, with reassessment at week 6. Dietary recommendations: reduce coffee, alcohol, and spicy foods. Increase dark leafy greens and blood-nourishing foods (beets, dates, goji berries). Recommend stress management: 10 minutes of diaphragmatic breathing before bed. Consider Xiao Yao San (Free and Easy Wanderer) herbal formula pending patient interest. Follow up on headache diary at next visit.
Documentation Tips for Acupuncture
- Always document tongue and pulse — these are essential for TCM pattern differentiation
- List all acupuncture points needled with bilateral notation
- Note de qi sensation and needle retention time
- Include the TCM pattern diagnosis alongside any Western correlation
- Document additional modalities (moxa, cupping, gua sha, e-stim) with location and duration
- Include dietary and lifestyle recommendations specific to the TCM pattern
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