Acupuncturist Template

Acupuncturist's SOAP Note

A professional Acupuncturist template for healthcare professionals.

About this template

This Acupuncturist's SOAP note template is designed for acupuncturists to document patient visits comprehensively. It includes sections for subjective patient experiences, objective physical assessments, and detailed treatment plans, including acupuncture points and additional modalities like cupping. This template is ideal for acupuncturists seeking to maintain thorough records of patient care, ensuring a holistic approach to treatment. By using this template with Heidi, acupuncturists can efficiently capture and organize patient information, enhancing the quality of care and facilitating effective treatment planning.

Preview template

Subjective: - Current Issues: Patient presents with chronic lower back pain persisting for 6 months, exacerbated by prolonged sitting and alleviated by stretching. - Patient's Description: The patient describes the pain as a dull ache with occasional sharp twinges, rated at 6/10 in severity. - Progression: Symptoms have gradually worsened over the past two months. - Impact on Daily Activities: Pain limits the patient's ability to perform daily tasks and affects work productivity. - Emotional State: The patient reports feeling stressed and anxious due to the persistent pain. - Lifestyle Factors: The patient follows a sedentary lifestyle with irregular exercise and poor sleep patterns. - Treatment History: Previous acupuncture sessions provided temporary relief. Past Medical History: - The patient has a history of lumbar disc herniation diagnosed two years ago. - Social History: Works a desk job with long hours. Objective: - Physical Examination: Pulse is wiry and rapid; tongue is pale with a thin white coating. - Vital Signs: BP 120/80, HR 72, Temp 98.6°F. Assessment: - Problem List: Chronic lower back pain. - Diagnosis: Kidney Qi deficiency with blood stasis. - Principles of Treatment: Tonify Kidney Qi and invigorate blood. Plan: - Treatment Plan: Acupuncture points used include BL23, BL25, and GV3 with moxibustion to warm the channels and alleviate pain. - Additional Modalities: Cupping therapy applied to the lower back. - Lifestyle Recommendations: Encourage regular stretching exercises and stress management techniques such as meditation. Additional Notes: - Follow-Up: Schedule next appointment in one week to assess progress and adjust treatment as necessary.

Subjective: - [current issues, reasons for visit, and history of presenting complaints] (include only if explicitly mentioned) - Patient's Description: [details of the patient's experience, symptoms, and concerns] (include only if explicitly mentioned) - [chief complaints such as requests, symptoms, and their context (e.g., duration, timing, location, quality, severity)] (include only if explicitly mentioned) - [factors that worsen or alleviate symptoms, including self-treatment attempts and effectiveness] (include only if explicitly mentioned) - Progression: [how symptoms have changed or evolved over time] (include only if explicitly mentioned) - Previous Episodes: [any past occurrences of similar symptoms, their management, and outcomes] (include only if explicitly mentioned) - Impact on Daily Activities: [how symptoms affect daily life, work, and activities] (include only if explicitly mentioned) - Associated Symptoms: [any additional focal or systemic symptoms accompanying chief complaints] (include only if explicitly mentioned) - Emotional State: [patient's emotional condition and stress levels] (include only if applicable) - Lifestyle Factors: [diet, exercise, sleep patterns] (include only if applicable) - Treatment History: [previous acupuncture treatments and outcomes] (include only if applicable) Past Medical History: - [details of past medical history, including medications, medical diagnosis, and conditions] (include only if explicitly mentioned) - [contributing factors such as past medical/surgical history relevant to the current visit] (include only if explicitly mentioned) - [social history relevant to the chief complaints] (include only if explicitly mentioned) - [family history relevant to the chief complaints] (include only if explicitly mentioned) - [exposure history] (include only if explicitly mentioned) - [immunization history and status] (include only if explicitly mentioned) - [any other relevant subjective information] (include only if explicitly mentioned) Objective: - Physical Examination: [findings from physical assessment, including pulse diagnosis and tongue observation] (include only if explicitly mentioned) - Vital Signs: [BP, HR, Temp, and other relevant measures] (include only if explicitly mentioned) Assessment: - [list issues, problems, or requests by name] (include only if explicitly mentioned) - [assessment or diagnosis related to identified issues] (include only if explicitly mentioned) - Problem List: [identified issues to be addressed] (include only if explicitly mentioned) - Diagnosis: [TCM diagnosis and differentiation] (include only if explicitly mentioned) - Principles of Treatment: [TCM principles of treatment] (include only if explicitly mentioned) Plan: - [treatment planned for each identified issue, including rationale] (include only if explicitly mentioned) - [treatment plan with acupuncture points used, technique, and rationale] (include only if explicitly mentioned) - [additional treatment modalities like E-stim, cupping, gua sha, tui na] (include only if explicitly mentioned) - Lifestyle Recommendations: [dietary advice, exercise, stress management techniques] (include only if explicitly mentioned) Additional Notes: - [relevant referrals for identified issues] (include only if explicitly mentioned) - Follow-Up: [next appointment scheduling and goals for the next session] (include only if explicitly mentioned) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned, leave the relevant placeholder or section blank.)

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