Complete Guide to Acupuncture SOAP Notes for Insurance

If you've ever stared at your computer at 9 p.m. trying to make your acupuncture SOAP notes look 'insurance ready,' you're not alone.

I've been there and so have most acupuncturists I know.

Insurance companies love detail, but your time is better spent with needles, than writing articles.

That's why I built a SOAP Notes Doctor to take the stress out of documentation.

In this article, I'll break down how to write acupuncture SOAP notes that meet insurance requirements.

🧾 What SOAP Notes Really Are (And Where They Came From)

SOAP notes might feel like a modern invention, but they've been around for decades.

They were first introduced in the 1960s by Dr. Lawrence Weed as part of something called the Problem-Oriented Medical Record (POMR).

His goal was simple: make patient documentation clear, consistent, and useful for both providers and anyone reviewing the chart later.

And that's really the spirit of SOAP notes.

They're a structured way of telling the story of what's happening with your patient.

SOAP stands for:

• S — Subjective: What the patient says (symptoms, pain levels, feelings).
• O — Objective: What you observe (tests, measurements, physical findings).
• A — Assessment: Your professional interpretation (diagnosis, progress).
• P — Plan: What you're going to do next (treatment, follow-ups).

This format keeps your documentation organized, easy to read, and easy to review which is exactly why insurance companies love it.

You want to write in a way that communicates clearly and professionally.

How You Can Approach SOAP Notes

There's no one right way to write SOAP notes but there are better ways depending on your workflow.

Here are my two approaches.

1. Traditional, Manual Notes

This is pen-and-paper or free-typing every section. It works well if you like to write things out and you have time to spare. The downside is it can be slow, and sometimes you end up with notes that aren't consistent from session to session.

2. SOAP Notes Doctor

You record your session and extra, rough sketchy contexts (if you need to e.g observation).

The tool formats everything neatly and keeps you compliant without hours of typing.

How to Make SOAP Notes Faster

One of the biggest frustrations I hear from practitioners is how much time SOAP notes eat up after a long day.

You've just finished treating patients, and instead of resting or preparing for tomorrow, you're staring at a blank screen trying to document everything in the right format.

The temptation in that moment is either to rush and leave things vague, or to overcompensate and write way too much.

Neither option is great.

The truth is, SOAP notes don't need to take forever, but they also can't be sloppy especially if you're submitting them for insurance.

Here's the trick we built:

✅ Head to soapnotes.doctor
✅ Record your session
✅ Save and generate notes automatically. right there. that same moment.
✅ Reclaim your weekends

With soapnotes.doctor, you can record a session, jot down rough texts, or even upload audio later, and the system automatically converts it into an industry-standard SOAP note.

That means you still get the clarity and compliance insurance companies want, but you don't have to type every word manually.

Maybe you have key observations you want to make?

Liver Qi stagnation, tenderness on palpation at L3–L5, etc.

Use the tailorr to add them. Keep it rough. Keep it sketchy and soapnotes.doctor still does the magic regardless.

Example 1

Patient: 35-year-old female
Chief Complaint: Chronic low back pain, worse after sitting for long periods.
Visit: 3 of 8 (out of a planned treatment course).

S – Subjective:

Patient reports low back pain rated 5/10 today, compared to 7/10 at initial visit. Pain worsens after sitting >1 hour. Reports mild morning stiffness and occasional radiating ache to right gluteal area. Sleep quality improved since last session (from 5/10 to 7/10).

O – Objective:

Palpation reveals tenderness at BL23, BL25, and GB30 on the right. Lumbar flexion limited to 70° with pain on end range. Pulse: wiry, slightly weak in Kidney position. Tongue: slightly pale with thin coating. Gait slightly guarded.

A – Assessment:

Low back pain secondary to Kidney deficiency with Qi stagnation. Improvement noted in pain severity and sleep quality since beginning treatment. Functional limitation persists with prolonged sitting, indicating continued need for care to achieve treatment goals.

P – Plan:

Acupuncture treatment: BL23, BL25, GV3, GV4, GB30, GB34, LI4, LR3. Electroacupuncture applied at BL23–BL25 for 15 min. Cupping therapy on lumbar region post-needling. Recommend continuing treatment 2x/week for 2 more weeks before reassessment. Home advice: gentle stretching, avoid prolonged sitting where possible.

Example 2

Patient: 42-year-old male
Chief Complaint: Tension-type headaches, worse at end of workday.
Visit: 5 of 10 (midway through planned treatment course).

S – Subjective:

Patient reports headaches now occurring 2–3 times per week, down from daily at initial visit. Describes pain as dull, bilateral, mostly frontal/temporal, rated 3/10 today (previously 6/10). Reports reduced neck and shoulder tension since starting acupuncture. Patient feels more relaxed and reports improved focus at work.

O – Objective:

Palpation reveals mild tightness along GB20 and trapezius bilaterally, improved from previous sessions. No visual disturbances noted. Pulse: wiry and slightly rapid. Tongue: thin white coating, slightly red tip. Blood pressure measured today at 122/78 mmHg (previously 135/80).

A – Assessment:

Tension headaches secondary to Liver Qi stagnation and stress-induced muscle tightness. Positive response to treatment, demonstrated by decreased frequency and intensity of headaches. Further care warranted to maintain improvements and address underlying stress patterns.

P – Plan:

Acupuncture treatment: LI4, LI11, GB20, GB34, LV3, DU20. Auricular points: Shenmen, Point Zero. Applied gentle cupping on upper back and shoulders for 10 minutes post-treatment. Recommended 1x/week sessions for next 5 weeks, reassess frequency after visit 10. Patient advised on breathing exercises during work breaks and maintaining ergonomic posture.