As an acupuncture practitioner, documenting your patient’s progress and treatment outcomes is a crucial aspect of providing quality care. Acupuncture SOAP notes (Subjective, Objective, Assessment, and Plan) are an organized way to record patient information and treatment details. Writing effective SOAP notes ensures accurate communication with other healthcare providers, facilitates continuity of care, and serves as essential legal documentation.
Subjective:
- Patient’s description of symptoms, including frequency, duration, and intensity.
- Relevant information about previous medications or treatments.
- Impact of the injury or condition on the patient’s daily life.
- Diagram to pinpoint specific areas of pain or discomfort.
Example:
“I have been experiencing severe lower back pain for the past week, and it becomes particularly uncomfortable when I am sitting down.”
Example: Patient complains of chronic lower back pain that started three months ago. Pain intensity varies from 5 to 8/10 and worsens after prolonged sitting or standing.
The best Acupuncture SOAP notes software allows patient intakes to auto-populate in the Subjective section of the SOAP. This way you can save time and have access to the patient’s history during the patient encounter.
Objective:
- Vital sign recordings, if relevant to the case.
- Results of any laboratory tests or x-rays conducted.
- Observation of swelling, discoloration, or any visible changes.
- Assessment of range of motion (ROM) and spine flexibility, if applicable.
Example:
During the examination, the patient displayed limited rotation in the L5-L5 region, and they reported experiencing pain. However, their left and right turns were within normal limits.
Example: Objective findings include limited lumbar spine range of motion, particularly in flexion and extension. Tenderness was noted in the lumbar paraspinal muscles.
Assessment:
- Diagnosis of the patient’s injury or condition.
- Observations on whether the patient’s condition has improved or worsened since the initial injury.
- General prognosis or expectations for the patient’s recovery.
Example:
The assessment suggests the presence of Qi-deficiency and blood stagnation. The patient has reported a worsening of symptoms since the injury occurred.
Example: Diagnosed with chronic lower back pain, possibly related to muscular strain or postural issues.
Plan:
- A detailed treatment plan tailored to the patient’s specific needs.
- Include the date and time of the next session.
- Describe the treatments provided during the current session.
Example:
The plan aims to stabilize the patient’s condition, control inflammation, and reduce spasms and pain.
Example: Performed acupuncture treatment targeting specific lumbar acupoints to alleviate pain and promote relaxation. Recommended core-strengthening exercises to support long-term pain management.
By using these comprehensive acupuncture SOAP notes examples, you can ensure that your notes contain all the necessary elements, providing a clear and accurate record of each patient’s progress and treatment journey. Effectively maintaining SOAP notes will enhance your practice’s efficiency, and communication with other healthcare professionals, and ultimately contribute to optimal patient care.
Acupuncture SOAP Notes Examples
Example 1: Patient: John Doe, 45, visited on November 13, 2023.
Subjective:
- Reports persistent lower back pain for six months.
Objective:
- Lumbar area exhibits tightness.
- Pulse is tense and rapid.
Assessment:
- Diagnosed with chronic Qi stagnation in the lower back.
Plans:
- Acupuncture at LV3, GB34.
- Recommend bi-weekly sessions and gentle yoga.
Example 2: Patient: Mary Smith, 30, visited on November 14, 2023.
Subjective:
- Experiencing stress-related insomnia and anxiety.
Objective:
- Rapid pulse.
- Tongue red with thin coating.
- Restlessness observed.
Assessment:
- Heart and Spleen Qi deficiency leading to insomnia.
Plans:
- Acupuncture at HT7, SP6, and ST36.
- Daily meditation and stress management advice.
Example 3: Patient: Alice Johnson, 50, visited on November 15, 2023.
Subjective:
- Frequent tension headaches, worsened by work stress.
Objective:
- Tender points at GB20.
- Tightness in neck muscles.
Assessment:
- Diagnosis of stress-induced tension headaches.
Plans:
- Acupuncture at LI4, GB20.
- Suggest relaxation techniques and regular breaks at work.
Tips for Writing Faster Acupuncture SOAP Notes
Acupuncture SOAP notes play a crucial role in billing accuracy, protecting your practice, and delivering optimal patient care. Although note-writing is time-consuming, there are effective methods to expedite the process and make it more efficient. By using acupuncture SOAP notes software or acupuncture practice management software, you can streamline your SOAP notes process.
Accurate and comprehensive SOAP notes are vital for efficient patient care in acupuncture practice. To expedite the note-writing process without compromising quality, consider the following time-saving tips:
1. Use SOAP Templates That Have Checkboxes
Simplify your SOAP notes by designing custom SOAP templates with checkboxes for common symptoms, treatments, and assessments. This method minimizes the need for extensive writing and allows you to quickly select relevant options. Customize the checkboxes to align with frequently encountered conditions and treatments.
Example:
- Back Pain
- Neck Pain
- Headache
- Improved ROM
- Reduced Inflammation
zHealth acupuncture software offers various acupuncture treatment notes templates, subjective, objective, plan, and other templates that you can choose and customize based on your unique needs.
2. Dictate Your Notes
To expedite the note-taking process, try using Voice Dictation software to dictate your SOAP notes. Speaking your notes can be faster than typing or writing, particularly if you are well-versed in medical terminology.
Example:
“Patient presents with moderate back pain, improved range of motion after treatment. Plan for ongoing sessions to address inflammation and optimize recovery.”
3. Use Acupuncture Practice Management Software
Leverage the power of acupuncture practice management software to streamline your SOAP note-writing. The best acupuncture software allows you to implement the above tips and more. With features like custom SOAP note templates, voice dictation, pain diagrams, and visual charting, the software simplifies the note-writing process significantly. By clicking on pre-set options for common text, you can save time and effort while ensuring consistent and accurate documentation.
Acupuncture SOAP Notes for Insurance Billing
Your acupuncture SOAP notes for insurance billing should include the correct CPT codes. The majority of services billed to insurance typically fall under four primary acupuncture CPT codes. Since acupuncture services are billed in 15-minute increments, your practice will utilize one code for the initial 15 minutes of service and a separate code for additional time units. Make sure to include these CPT codes based on treatments provided, conditions, new or returning patients.
97810 Initial Acupuncture: Initial 15-minute needle insertion, one-on-one patient contact. (Do not report with 97813; use one or the other.)
97811 Subsequent Unit of Acupuncture: One unit for each additional 15 minutes of patient contact after the initial 15 minutes, with needle re-insertion. (May be used with 97810 or 97813)
97813 Initial Acupuncture with Electrical Stimulation: Initial 15-minute needle insertion, one-on-one patient contact. (Do not report with 97810; use one or the other.)
97814 Subsequent Unit of Acupuncture with Electrical Stimulation: One unit for each additional 15 minutes of patient contact, with needle re-insertion. (May be used with 97810 or 97813)
Acupuncture CPT Codes for Medicare to be included in SOAP Notes
In January, Medicare expanded coverage to include acupuncture for treating chronic lower back pain. CPT codes for billing Medicare for acupuncture treatments are:
97810: Acupuncture without electrical stimulation, initial 15 minutes of patient contact
97811: Each additional 15 minutes of patient contact, with needle re-insertion
97813: Acupuncture with electrical stimulation, initial 15 minutes of patient contact
97814: Each additional 15 minutes of patient contact, with needle re-insertion
20560: Needle insertion(s) without injection(s) of 1 or 2 muscle(s) 20561: Needle insertion(s) without injection(s) of 3 or more muscle(s)
2023 Billing Codes for New Patients
Use these acupuncture CPT codes for new patients, defined as those who haven’t received services from you or another provider of the same specialty within the past three years.
99202 Evaluation/Management (Expanded): Low to moderate severity; requires expanded history, examination, and straightforward decision-making; 20 minutes face-to-face 99203
Evaluation/Management (Detailed): Moderate severity; requires detailed history, examination, and low complexity decision-making; 30 minutes face-to-face
99204 Evaluation/Management (Comprehensive): Moderate to high severity; requires comprehensive history, examination, and moderate complexity decision-making; 45 minutes face-to-face
Billing Codes for Returning Patients
Use these CPT codes on your SOAP notes for established patients who have received services from you or another provider of the same specialty within the past three years.
99212 Evaluation/Management (Limited): Self-limited or minor problems; requires problem-focused history, examination, and straightforward decision-making; 10 minutes face-to-face
99213 Evaluation/Management (Expanded): Low to moderate severity problems; requires expanded history, examination, and low complexity decision-making; 15 minutes face-to-face
99214 Evaluation/Management (Detailed): Moderate to high severity problems; requires detailed history, examination, and moderate complexity decision-making; 25 minutes face-to-face
Conclusion
Acupuncture SOAP notes play a crucial role in billing accuracy, protecting your practice, and delivering optimal patient care. Although note-writing is time-consuming, there are effective methods to expedite the process and make it more efficient. By using acupuncture SOAP notes software or acupuncture practice management software, you can streamline your SOAP notes process.
With zHealth acupuncture software, you can create faster SOAP notes and even dictate them. Add your CPT codes to the invoice. Once you complete them, send the acupuncture SOAP notes pdf file to patients in the form on billing statement.
Interested in discovering the benefits of zHealth acupuncture practice management software? Schedule a demo with a zHealth product specialist today and explore how it can enhance your practice’s productivity and patient care.
