Acupuncture SOAP Notes (with Examples)

SOAP notes are a simple and clear way to document patient care. In acupuncture practice, SOAP notes help track symptoms, treatment points, patient response, and progress over time. They also support safe care, clear communication, and legal protection. Many acupuncturists work with patients who return for multiple sessions, so written records are very important. SOAP notes make sure that nothing important is missed and that each visit builds on the last one.

Acupuncture SOAP notes are not complex, but they must be complete. They should explain why the patient came, what was observed, what the practitioner believes is happening, and what treatment was given. When written in simple language, SOAP notes are easy to read later and easy to share if needed. Good notes also help the acupuncturist notice patterns, such as which points help the most or how fast symptoms change. In this guide, we will explain how to write SOAP notes for acupuncture. You will also find full SOAP note examples for common acupuncture visits, including pain, stress, digestion, and sleep problems.

What Are SOAP Notes in Acupuncture?

SOAP notes are a structured way to write patient notes. The word SOAP stands for Subjective, Objective, Assessment, and Plan. Each letter represents one part of the note. This structure helps keep notes organized and easy to follow, even when visits happen weeks or months apart.

In acupuncture, SOAP notes are slightly different from Western medical notes, but the structure stays the same. The Subjective section focuses on how the patient feels and what they report. The Objective section includes what the practitioner sees, feels, or measures. The Assessment section combines both Western and Traditional Chinese Medicine (TCM) thinking. The Plan section explains the acupuncture points used, the techniques applied, and the follow-up plan.

Using SOAP notes helps acupuncture clinics stay consistent. If more than one practitioner sees the patient, SOAP notes allow smooth care. They also help students and new practitioners learn how to think clearly about diagnosis and treatment. Over time, SOAP notes become a powerful tool for better clinical judgment.

Why SOAP Notes Are Important for Acupuncture Care

SOAP notes help protect both the patient and the practitioner. Clear documentation shows that care was thoughtful, planned, and based on patient needs. If a patient has questions later, the notes help explain what was done and why. If there is ever a legal or insurance issue, SOAP notes provide written proof of care.

Another important reason is treatment quality. Acupuncture often works best over several sessions. SOAP notes help track changes in pain, energy, sleep, digestion, and mood. Without notes, it is easy to forget small but important details. With notes, progress becomes visible, and treatment can be adjusted more accurately.

SOAP notes also improve communication. If a patient is referred by another provider or needs records shared, clear notes make that process smooth. When written in simple words, SOAP notes are useful not only for professionals but also for patients who want to understand their care better.

How Acupuncture SOAP Notes Are Different

Acupuncture SOAP notes often include both Western terms and TCM concepts. For example, a patient may report knee pain, but the assessment might mention Qi stagnation or Kidney deficiency. This mix is normal and helpful. The key is to keep language clear and consistent.

Another difference is the treatment detail. Acupuncture notes usually list specific points used, needle depth, stimulation type, and retention time. These details matter because they help repeat successful treatments and avoid mistakes. Over time, these details show patterns that improve results.

Acupuncture SOAP notes often include lifestyle advice, such as diet, stress care, or exercise. These recommendations are part of holistic care and should be documented. Writing them in the Plan section makes the visit feel complete and professional.

Subjective (S): What the Patient Reports

The Subjective section records what the patient says in their own words. This includes the main complaint, symptom history, and how the patient feels since the last visit. Pain level, location, timing, and triggers are important details. Emotional state, sleep quality, digestion, and energy should also be noted when relevant.

In acupuncture, the Subjective section may include questions about temperature sensitivity, thirst, appetite, bowel habits, menstruation, and stress. These details help guide TCM diagnosis. It is important to write clearly and avoid guessing. Only write what the patient reports, not what you assume.

Longer Subjective notes are often helpful, especially at the first visit. Over time, follow-up notes may be shorter but should still capture changes. Writing in full sentences using simple words makes the note easy to read later.

Objective (O): What You Observe

The Objective section includes what the practitioner observes or measures. This may include posture, facial color, tongue appearance, pulse quality, range of motion, and visible swelling or tension. These findings support the assessment, but should be factual and clear.

In acupuncture practice, tongue and pulse findings are common. For example, noting a pale tongue with a thin coat or a wiry pulse helps explain the treatment choice. These details should be written simply, without long theoretical explanations.

If tools are used, such as heat lamps or cupping marks, they can also be noted here. The key rule is that Objective notes are based on observation, not opinion. Keeping this section clear helps separate facts from interpretation.

Assessment (A): Clinical Impression

The Assessment section explains what the practitioner believes is happening. This may include a Western diagnosis, a TCM pattern, or both. For example, a patient may have chronic low back pain with Kidney Qi deficiency. Writing both helps create a full picture.

This section does not need to be very long, but it should be thoughtful. It connects the Subjective and Objective findings into one clear understanding. Changes since the last visit should also be noted, such as improvement or worsening of symptoms.

Writing the Assessment clearly helps guide future care. When reviewing old notes, this section explains the logic behind treatment decisions. Over time, it becomes a record of clinical reasoning and patient progress.

Plan (P): Treatment and Next Steps

The Plan section describes exactly what was done during the session. This includes acupuncture points used, needle technique, retention time, and any additional therapies such as cupping, moxibustion, or electro-acupuncture. It should also include patient education and home care advice.

Future plans are also written here. This may include treatment frequency, goals for the next visit, and when progress will be reviewed. If referrals or lifestyle changes are suggested, they should be documented clearly.

A strong Plan section shows professionalism and care. It helps ensure that each visit follows a clear path instead of feeling random. When written well, it supports both patient trust and clinical success.

Acupuncture SOAP Note Examples:

Chronic Low Back Pain

Subjective (S)

The patient reports chronic low back pain that has been present for the past four years. The pain is described as a dull, deep ache located mainly in the lower lumbar area, with occasional stiffness spreading to both hips. The pain is worse in the early morning and after long periods of sitting, and it improves slightly with gentle movement and heat. Today, the patient rates the pain as 6 out of 10. There is no sharp or shooting pain in the legs.

The patient also reports general fatigue, low energy in the afternoon, and sensitivity to cold, especially in the lower back area. Sleep is light but not interrupted by pain. The patient denies any recent injury or trauma. Over-the-counter pain medication provides only mild and temporary relief.

Objective (O)

Observation shows a slightly guarded posture with reduced flexibility when standing up from a seated position. Palpation reveals muscle tightness and mild tenderness in the lumbar paraspinal muscles. Range of motion in the lower back is limited, especially with extension, and stiffness is noted rather than sharp pain.

Tongue appears pale with a thin white coating. Pulse is deep and weak, especially in the Kidney position. The lower back area feels cool to the touch compared to the surrounding areas. No visible swelling or redness is present.

Assessment (A)

Chronic low back pain consistent with Kidney Qi deficiency and underlying weakness, combined with local muscle tension. The long duration of symptoms, cold sensitivity, fatigue, and a deep, weak pulse suggest a deficiency pattern rather than an acute condition. Symptoms appear stable but persistent, indicating the need for ongoing supportive treatment.

Plan (P)

Acupuncture treatment was provided to the patient in a prone position. Points used include BL23, BL25, BL40, GV3, DU4, and KI3. Sterile needles were inserted with gentle manual stimulation and retained for 25 minutes. A heat lamp was applied to the lower back during treatment to support warming and relaxation.

The patient was advised to keep the lower back warm, avoid prolonged sitting, and engage in gentle stretching exercises. Light walking was encouraged to support circulation. Treatment is planned once per week for four weeks, with reassessment of pain level, mobility, and energy at the next visit.

Tension Headache and Stress

Subjective (S)

The patient reports frequent tension headaches for the past six months. Headaches occur three to four times per week and usually begin in the neck and shoulders before moving up to the sides of the head and temples. The pain feels tight and pressing rather than sharp or throbbing. During headache episodes, the patient rates the pain as 5 out of 10. Headaches often worsen in the late afternoon or after stressful workdays.

The patient reports high stress levels related to work responsibilities and difficulty relaxing. Jaw clenching and shoulder tightness are common, especially during the day. Sleep quality is poor, with trouble falling asleep and waking up feeling unrefreshed. The patient denies nausea, vomiting, or sensitivity to light. No history of migraines is reported.

Objective (O)

Observation shows elevated shoulders and a forward head posture. Palpation reveals tight and tender muscles in the neck, upper shoulders, and jaw area. Range of motion in the neck is slightly limited due to stiffness. The patient appears tense but alert and cooperative during the visit.

The tongue is slightly red along the sides with a thin coating. Pulse is wiry and slightly rapid. Breathing appears shallow, especially during discussion of stress. No neurological deficits are observed.

Assessment (A)

Tension headaches are associated with Liver Qi stagnation due to ongoing emotional stress. Muscle tension in the neck and shoulders contributes to reduced circulation and headache pain. Poor sleep and jaw clenching further aggravate symptoms. The condition is chronic but functional.

Plan (P)

Acupuncture treatment was performed with the patient in a supine position. Points used include GB20, LI4, LV3, SJ5, Yintang, and GB21. Sterile needles were inserted with mild manual stimulation and retained for 20 minutes. The patient was guided through slow breathing during treatment to support relaxation.

The patient was advised to take short breaks during work, practice jaw relaxation, and stretch the neck and shoulders daily. Reducing screen time before bed and establishing a calming evening routine were recommended. Treatment is planned once weekly for three weeks, with reassessment of headache frequency, stress level, and sleep quality at the next visit.

Digestive Issues and Bloating

Subjective (S)

The patient has reported ongoing digestive discomfort and bloating for the past seven months. Bloating usually starts within one hour after eating and is worse in the afternoon and evening. The patient describes a heavy and full feeling in the abdomen rather than sharp pain. Symptoms are worse after eating cold foods, dairy, or greasy meals. Today, the discomfort level is rated as 5 out of 10.

The patient reports a normal appetite but feels tired after meals. Bowel movements occur once daily and are loose in consistency. There is occasional gas but no severe cramping. The patient also reports low energy, especially in the late afternoon, and mild worry or overthinking. No nausea, vomiting, or significant weight changes are reported.

Objective (O)

The abdomen appears soft on inspection, with mild tenderness around the umbilical area on palpation. No guarding or sharp pain is noted. The patient’s posture is relaxed, but the voice sounds tired and low in strength.

Tongue appears pale with scalloped edges and a thin white coating. Pulse is soft and weak, especially in the Spleen position. Extremities feel slightly cool to the touch. No signs of acute infection or inflammation are present.

Assessment (A)

Digestive issues and bloating are consistent with Spleen Qi deficiency. Poor transformation and transportation of food and fluids are contributing to bloating, loose stools, and post-meal fatigue. Emotional overthinking may further weaken digestive function. Condition is chronic but stable.

Plan (P)

Acupuncture treatment was provided to the patient in a supine position. Points used include ST36, SP6, SP3, CV12, and ST29. Sterile needles were inserted with gentle manual stimulation and retained for 25 minutes. A mild warming technique was used on the abdomen to support digestion.

Dietary advice was given to focus on warm, cooked meals and to avoid cold drinks and greasy foods. The patient was encouraged to eat regular meals and chew food slowly. Treatment is planned once per week for four weeks, with reassessment of bloating, bowel movements, and energy levels at the next visit.

Common Mistakes and Tips for Writing Better Acupuncture SOAP Notes

Mistakes

Many acupuncture SOAP notes are too short and miss important details. Writing only “patient feels better” does not explain how or why. Always include pain levels, symptom changes, and specific observations to make the note useful.

Another common mistake is mixing sections. For example, writing opinions in the Objective section can cause confusion. Keep patient statements in Subjective and observations in Objective. This separation keeps notes clear and professional.

Some notes also forget to document treatment details. Acupuncture points, time, and techniques matter. Without them, it is hard to repeat successful sessions or understand what worked best.

Tips

Use simple words and full sentences. Avoid long theory explanations in the note. The goal is clarity, not showing knowledge. Clear notes are easier to review and safer for care.

Be consistent in how you write. Use the same format each time, so notes are easy to compare. Over time, this consistency saves time and reduces mistakes.

Write notes soon after the session. Waiting too long increases the chance of forgetting details. Fresh notes are more accurate and more helpful.

Final Thoughts

SOAP notes for acupuncture are not just routine paperwork. They help you think clearly, track real progress, and provide safer and more consistent care. When notes are written in simple and clear language, they tell the full story of the patient’s healing over time and make each session more meaningful. By following the SOAP structure, acupuncture notes become easier to write and easier to review later. Clear documentation builds trust with patients, supports better treatment decisions, and leads to stronger long-term results for both the practitioner and the patient.