Acupuncture SOAP Note

Nota preenchida

Subjective:
- Reports intermittent upper back tightness for several weeks, worse after desk work and eased by walking and a warm shower.
- Describes a dull, nonradiating ache, usually mild; denies weakness, numbness, fever, or recent injury.
- Similar discomfort occurred during a busy work period and improved with stretching. It now interrupts sleep occasionally but does not prevent usual activities.
- Reports moderate work stress, regular meals, light exercise, and variable sleep. No prior acupuncture treatment.

Past Medical History:
- No chronic conditions or surgeries reported. Uses no regular medication and reports no known allergies.
- No relevant family or exposure history reported; immunization status not discussed.

Objective:
- Physical Examination: Mild bilateral upper trapezius tenderness; neck movement intact. Tongue light pink with thin white coating; pulse described as slightly wiry.
- Vital Signs: Not recorded.

Assessment:
- Upper back tightness, likely related to sustained posture and muscle tension.
- TCM differentiation: Qi stagnation; treatment principle is to move Qi and relax the channels.

Plan:
- Acupuncture at selected local and distal points with gentle manual stimulation; reassess response.
- Recommend regular movement breaks, gentle stretching, and a consistent wind-down routine.

Additional Notes:
- Consider medical evaluation if symptoms worsen or neurologic symptoms develop.
- Follow up to assess comfort and functional response.

Caso ilustrativo com dados de paciente inventados. Não é um registo real de paciente nem orientação clínica. Reveja cada nota à luz da sua própria consulta.

Factos clínicos por trás da nota

Estrutura reutilizável do modelo

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]