S (Subjective): This section captures the patient’s perspective on their health concerns.
Chief Complaint (CC): Briefly describe the patient’s primary reason for seeking TCM treatment in their own words.
History of Present Illness (HPI): Here, delve deeper into the patient’s experience with the chief complaint. Include details like onset, progression, aggravating/alleviating factors, and associated symptoms. Explore the patient’s perspective on how these symptoms affect their daily life and overall well-being.
O (Objective): This section documents your findings from the TCM examination.
Traditional Diagnostic Methods: Describe your findings from techniques like pulse diagnosis, tongue diagnosis, and inquiry about signs and symptoms according to TCM principles.
Physical Examination: Include relevant findings from a physical exam that complement the TCM assessment.
A (Assessment): This section integrates your findings to formulate a TCM diagnosis and identify potential underlying imbalances.
TCM Pattern Diagnosis: Based on the information gathered, formulate a TCM pattern diagnosis using established TCM terminology.
Western Medical Correlation (Optional): If applicable, consider including a brief correlation with a potential Western medical diagnosis, but prioritize the TCM perspective.
P (Plan): This section outlines the treatment plan for the patient.
Treatment Modalities: List the specific TCM modalities you plan to use, such as acupuncture, herbal medicine, tui na (massage), dietary therapy, or cupping therapy.
Treatment Frequency and Duration: Specify the recommended frequency and duration of the treatment plan.
Self-care Recommendations: Include any self-care recommendations, such as dietary modifications, lifestyle adjustments, or exercises aligned with TCM principles.
Follow-up: Schedule the next appointment for follow-up assessment and potential adjustments to the treatment plan.
Additional Considerations
Document medications: Include any medications the patient is taking, both conventional and herbal. Note any potential interactions with the TCM treatment plan.
Progress notes: For subsequent visits, document the patient’s response to treatment and any modifications made to the plan.
Legal and regulatory requirements: Ensure your notes comply with all relevant legal and regulatory requirements for medical record keeping in your jurisdiction.
By adapting a SOAP note format with these TCM-specific elements, you can create a comprehensive and informative record of your TCM encounters. Remember to tailor the details to your specific practice and the unique needs of each patient.