Acupuncture SOAP Note

Valmis merkintä

Esimerkki — Notatin luoma esimerkikäynnistä

Presenting concern:
Shoulder stiffness and discomfort with overhead reaching, developing gradually over six weeks.

Assessment:
Movement restriction affecting daily activity.

Plan:
Agreed a graded home exercise programme and activity modification. Review progress in three weeks.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Malli

Subjective:
(hyphenated list)
- [Current issues, reasons for visit, and history of presenting complaints]
- Patient's Description: [Details of the patient's experience, symptoms, and concerns]
- [Chief complaints such as requests, symptoms, and their context (e.g., duration, timing, location, quality, severity)]
- [Factors that worsen or alleviate symptoms, including self-treatment attempts and effectiveness]
- Progression: [How symptoms have changed or evolved over time]
- Previous Episodes: [Any past occurrences of similar symptoms, their management, and outcomes]
- Impact on Daily Activities: [How symptoms affect daily life, work, and activities] 
- Associated Symptoms: [Any additional focal or systemic symptoms accompanying chief complaints]
- Emotional State: [Patient's emotional condition and stress levels] 
- Lifestyle Factors: [Diet, exercise, sleep patterns]
- Treatment History: [Previous acupuncture treatments and outcomes]

Past Medical History:
(hyphenated list)
- [Details of past medical history, including medications, medical diagnosis, and conditions]
- [Contributing factors such as past medical/surgical history relevant to the current visit]
- [Social history relevant to the chief complaints] 
- [Family history relevant to the chief complaints]
- [Exposure history] 
- [Immunization history and status]
- [Any other relevant subjective information]

Objective:
(hyphenated list)
- Physical Examination: [Findings from physical assessment, including pulse diagnosis and tongue observation]
- Vital Signs: [BP, HR, Temp, and other relevant measures]

Assessment:
(hyphenated list)
- [List issues, problems, or requests by name]
- [Assessment or diagnosis related to identified issues]
- Problem List: [Identified issues to be addressed]
- Diagnosis: [TCM diagnosis and differentiation]
- Principles of Treatment: [TCM principles of treatment]

Plan:
(hyphenated list)
- [Treatment planned for each identified issue, including rationale]
- [Treatment plan with acupuncture points used, technique, and rationale]
- [Additional treatment modalities like E-stim, cupping, gua sha, tui na]
- Lifestyle Recommendations: [Dietary advice, exercise, stress management techniques]

Additional Notes:
(hyphenated list)
- [Relevant referrals for identified issues]
- Follow-Up: [Next appointment scheduling and goals for the next session]