The 2026 Guide to Writing 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 demand detailed documentation, but your time is better spent with needles than writing lengthy reports.

The challenge is real: insurance reviewers want clear evidence of medical necessity, measurable progress, and treatment plans that align with standard protocols.

That's exactly why I built SOAP Notes Doctor to take the stress out of documentation while ensuring compliance.

In this article, I'll break down how to write acupuncture SOAP notes that meet insurance requirements without consuming your evenings and weekends.

🧾 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.

For acupuncture specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of patient symptoms and functional limitations
• Objective measurements showing treatment progress
• Medical necessity for continued care
• Evidence-based treatment approaches using TCM diagnosis
• Appropriate treatment frequency and duration

SOAP stands for:

• S — Subjective: What the patient says (symptoms, pain levels, feelings, functional limitations).
• O — Objective: What you observe (tests, measurements, physical findings, tongue and pulse diagnosis).
• A — Assessment: Your professional interpretation (TCM diagnosis, progress toward treatment goals, medical necessity).
• P — Plan: What you're going to do next (specific acupuncture points, adjunct therapies, treatment frequency, home care recommendations).

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

You want to write in a way that communicates clearly and professionally while demonstrating the clinical value of acupuncture treatment.

How You Can Approach Acupuncture SOAP Notes

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

Here are two main approaches I've seen work effectively.

1. Traditional, Manual Documentation

This is pen-and-paper or free-typing every section after each treatment. It works well if you see a manageable patient load and enjoy detailed writing. The downside is it can be time-consuming and slow, and sometimes you end up with notes that aren't consistent from session to session or between different practitioners in your clinic.

2. SOAP Notes Doctor

You record your session observations and add rough, sketchy notes about specific findings if needed.

The tool formats everything into proper SOAP structure automatically and keeps you compliant without hours of typing.

This approach maintains consistency, saves significant documentation time, and ensures you never miss critical components that insurance reviewers look for.

How to Make Acupuncture SOAP Notes Faster

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

You've just finished seeing 8-12 patients, performing detailed assessments and individualized treatments, 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 for insurance compliance or your work-life balance.

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 reimbursement.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your session observations during or immediately after treatment
✅ Save and generate properly formatted notes automatically
✅ Reclaim your evenings and weekends

With soapnotes.doctor, you can record a session, jot down rough notes about key findings, or even upload audio later, and the system automatically converts it into an insurance-compliant SOAP note.

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

Maybe you have key observations you want to include?

Liver Qi stagnation, tenderness on palpation at L3–L5, wiry pulse, pale tongue with thin coating, limited lumbar flexion to 70 degrees.

Use the tailorr feature to add them. Keep it rough and unpolished—soapnotes.doctor handles the formatting regardless.

Example 1: Chronic Low Back Pain Treatment Session

Patient: 35-year-old female
Chief Complaint: Chronic low back pain, worse after sitting for long periods
Visit: Session 3 of 8 (planned treatment course)
ICD-10 Code: M54.5 (Low back pain)

S – Subjective:

Patient reports low back pain rated 5/10 today, compared to 7/10 at initial visit. Pain worsens after sitting longer than 1 hour at work desk. Reports mild morning stiffness lasting approximately 15 minutes, improved from 30 minutes at baseline. Occasional radiating ache to right gluteal area, no numbness or tingling. Sleep quality improved since last session (from 5/10 to 7/10). Able to complete daily activities with less discomfort. Previously tried physical therapy with minimal lasting relief. Currently taking ibuprofen 400mg as needed, reduced from daily to 2-3 times weekly.

O – Objective:

Vital Signs: BP 118/76, HR 72
Palpation: Tenderness at BL23 (Shenshu), BL25 (Dachangshu), and GB30 (Huantiao) on the right. Lumbar flexion limited to 70° with pain on end range (normal 90°). Lumbar extension within normal limits without pain.
TCM Diagnosis: Pulse wiry, slightly weak in Kidney position bilaterally. Tongue slightly pale with thin white coating, minimal tooth marks on lateral edges.
Gait: Slightly guarded with reduced lumbar movement during walking.
Functional Assessment: Patient able to sit for 45 minutes without significant pain increase (baseline 20 minutes).

A – Assessment:

Chronic low back pain secondary to Kidney deficiency with Qi and Blood stagnation in lower back channels. Demonstrable improvement noted in pain severity (reduced from 7/10 to 5/10), sleep quality, and sitting tolerance since beginning treatment. Functional limitation persists with prolonged sitting and morning stiffness, indicating continued need for care to achieve treatment goals of pain reduction to 2/10 or less and restoration of normal daily function. Patient progressing appropriately toward goals within expected treatment timeline.

P – Plan:

Acupuncture Treatment: Bilateral points BL23 (Shenshu), BL25 (Dachangshu), GV3 (Yaoyangguan), GV4 (Mingmen), right GB30 (Huantiao), bilateral GB34 (Yanglingquan), LI4 (Hegu), LR3 (Taichong). Needles retained 25 minutes.
Electroacupuncture: Applied at BL23–BL25 bilaterally, 2 Hz frequency for 15 minutes to promote Qi and Blood circulation.
Adjunct Therapy: Cupping therapy on lumbar region post-needling for 10 minutes to release muscle tension and promote Blood flow.
Treatment Frequency: Continue 2x/week for 2 more weeks (4 additional sessions), then reassess progress and adjust frequency as appropriate.
Home Care Recommendations: Gentle lumbar stretches demonstrated in office (cat-cow, child's pose), perform daily. Avoid prolonged sitting when possible, take standing breaks every 30-45 minutes. Apply heat to lower back for 15-20 minutes in evening as needed.
Next Visit: Scheduled in 3 days. Will reassess pain levels, functional capacity, and treatment response.

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Example 2: Tension Headaches Midway Through Treatment

Patient: 42-year-old male
Chief Complaint: Tension-type headaches, worse at end of workday
Visit: Session 5 of 10 (midway through planned treatment course)
ICD-10 Code: G44.209 (Tension-type headache, unspecified)

S – Subjective:

Patient reports headaches now occurring 2–3 times per week, significantly reduced from daily occurrence at initial visit. Describes pain as dull, bilateral, mostly frontal and temporal regions, rated 3/10 today (previously 6/10 at baseline). Duration of headaches reduced from 4-6 hours to 1-2 hours. Reports reduced neck and shoulder tension since starting acupuncture. Patient feels more relaxed overall and reports improved focus and productivity at work. No longer requiring daily over-the-counter pain medication (previously taking acetaminophen 1000mg daily). Denies nausea, visual disturbances, or photophobia. Stress levels at work remain high but patient reports feeling better equipped to handle demands.

O – Objective:

Vital Signs: BP 122/78, HR 74
Palpation: Mild muscle tightness along GB20 (Fengchi) and upper trapezius bilaterally, notably improved from previous sessions (moderate-severe tightness at baseline). No trigger points elicited today.
Neurological: No visual disturbances noted, pupils equal and reactive, cranial nerves II-XII grossly intact.
TCM Diagnosis: Pulse wiry and slightly rapid, less wiry than at baseline. Tongue with thin white coating, slightly red tip indicating residual Heat.
Functional Assessment: Patient reports improved neck range of motion, able to work at computer for full day without severe headache onset.

A – Assessment:

Tension-type headaches secondary to Liver Qi stagnation and stress-induced muscle tightness with improving Heat signs. Positive clinical response to treatment demonstrated by 70% reduction in headache frequency (from 7 days/week to 2-3 days/week) and 50% reduction in pain intensity (from 6/10 to 3/10). Blood pressure improved from baseline 135/80 to current 122/78. Functional improvements noted in work performance and stress management. Treatment plan appropriately addressing underlying patterns. Continued care warranted to maintain improvements and further address underlying stress patterns to prevent recurrence.

P – Plan:

Acupuncture Treatment: Bilateral points LI4 (Hegu), LI11 (Quchi), GB20 (Fengchi), GB34 (Yanglingquan), LV3 (Taichong), DU20 (Baihui) to regulate Liver Qi, clear Heat, and calm Shen. Needles retained 30 minutes.
Auricular Acupuncture: Shenmen and Point Zero for stress reduction and autonomic nervous system regulation.
Adjunct Therapy: Gentle cupping applied to upper back and shoulders for 10 minutes post-treatment to release remaining muscle tension.
Treatment Frequency: Reduce to 1x/week sessions for remaining 5 weeks based on positive response, then reassess frequency after visit 10. May transition to maintenance care (2x/month) if improvements continue.
Home Care Recommendations: Continue practicing breathing exercises during work breaks (demonstrated 4-7-8 breathing technique). Maintain ergonomic workstation setup as previously discussed. Consider stress management techniques such as brief meditation or walking during lunch break.
Next Visit: Scheduled in 7 days. Will monitor headache frequency, intensity, and any changes in stress levels or work demands.

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Example 3: Chronic Neck Pain with Limited Range of Motion

Patient: 58-year-old female
Chief Complaint: Chronic neck pain and stiffness, difficulty turning head
Visit: Session 7 of 12 (established treatment course)
ICD-10 Code: M54.2 (Cervicalgia)

S – Subjective:

Patient reports neck pain rated 4/10 at rest, increasing to 6/10 with prolonged computer work. Pain has decreased from baseline 7/10 at rest. Describes stiffness and reduced range of motion when turning head to check blind spots while driving. Morning stiffness duration reduced from 2 hours at initial visit to 30-45 minutes currently. Reports occasional headaches radiating from neck base to occiput, occurring 1-2 times weekly (down from 5-6 times weekly). Sleep position adjustments recommended in previous sessions have been helpful. Denies arm numbness, tingling, or weakness. Patient works as administrative assistant, sitting 6-8 hours daily. Previously attempted chiropractic care with temporary relief only.

O – Objective:

Vital Signs: BP 126/82, HR 70
Range of Motion: Cervical rotation right 60° (limited, normal 80°), left 65° (limited), lateral flexion right 30° (limited, normal 45°), left 35° (limited). Flexion and extension within normal limits with mild discomfort at end range.
Palpation: Moderate tenderness and muscle tension at GB20 (Fengchi) bilaterally, GB21 (Jianjing) bilaterally, and SI3 (Houxi) region. Upper trapezius hypertonic bilaterally.
TCM Diagnosis: Pulse wiry and thin. Tongue pale with thin white coating.
Neurological: Spurling's test negative bilaterally, no radicular symptoms.
Functional Assessment: Patient demonstrates improved ability to turn head for driving (previously avoided highway driving due to limited mobility).

A – Assessment:

Chronic cervicalgia with restricted cervical rotation and lateral flexion secondary to Blood stagnation and Cold obstruction in neck channels, likely related to occupational postural strain. Improvement demonstrated in pain intensity (43% reduction from baseline), morning stiffness duration (60% reduction), and headache frequency (70% reduction). Range of motion showing gradual improvement with 10-15° gains in rotation and lateral flexion since baseline measurements. Functional capacity improving with patient resuming previously avoided activities. Continued treatment necessary to achieve full range of motion and sustained pain reduction goals.

P – Plan:

Acupuncture Treatment: Bilateral GB20 (Fengchi), GB21 (Jianjing), SI3 (Houxi), LI4 (Hegu), BL10 (Tianzhu), GV14 (Dazhui), GV16 (Fengfu) to move Qi and Blood, dispel Cold, and relax tendons. Needles retained 30 minutes with manual stimulation every 10 minutes.
Adjunct Therapies: Gua sha applied to cervical paraspinal muscles and upper trapezius to release adhesions and promote circulation. Gentle cervical mobilization techniques performed. Infrared heat lamp applied to neck and upper back for 15 minutes during needle retention.
Treatment Frequency: Continue 1x/week for remaining 5 sessions of current treatment plan, then reassess. Anticipate transitioning to maintenance schedule (2x/month) if improvements continue at current rate.
Home Care Recommendations: Continue performing gentle cervical stretches (demonstrated chin tucks, shoulder rolls, levator scapulae stretch) 2-3 times daily, especially during work breaks. Use heat pack on neck for 15 minutes before bed. Reinforce proper workstation ergonomics including monitor height and keyboard placement. Consider using lumbar support cushion while working.
Referral Consideration: If range of motion does not continue improving over next 3 sessions, may consider physical therapy referral for complementary manual therapy.
Next Visit: Scheduled in 7 days for continued treatment and range of motion reassessment.

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Key Components Insurance Companies Look For in Acupuncture SOAP Notes

When reviewing your acupuncture documentation, insurance companies and medical reviewers specifically want to see:

1. Clear Chief Complaint and Functional Limitations

Document what's wrong and how it affects daily life. "Back pain" isn't enough—describe functional impact: "unable to sit for more than 20 minutes at work desk."

2. Measurable Objective Findings

Include pain scales, range of motion measurements, functional assessments, and TCM diagnostic findings (pulse, tongue). These show baseline and track progress.

3. Evidence of Medical Necessity

Document why acupuncture is needed, what else has been tried, and why treatment should continue. Show that care is reasonable and necessary.

4. Treatment Goals with Timeline

Establish clear, measurable goals at treatment outset. Document progress toward these goals at each visit to justify continued care.

5. Specific Treatment Details

List exact acupuncture points used, needle retention time, adjunct therapies (cupping, electroacupuncture, moxibustion), and rationale for point selection.

6. Progress Documentation

Show improvement (or explain lack thereof) using objective measures. Compare current findings to baseline and previous visits.

7. Treatment Plan and Frequency Justification

Explain why you're recommending specific treatment frequency (2x/week vs 1x/week) and when you'll reassess or adjust the plan.

8. Patient Education and Home Care

Document self-care instructions, lifestyle modifications recommended, and patient compliance with previous recommendations.

Common Mistakes to Avoid in Acupuncture SOAP Notes

Vague Symptom Documentation: Instead of "patient feels better," document specific measurable changes: "pain reduced from 7/10 to 4/10, sitting tolerance increased from 20 to 45 minutes."

Missing Functional Limitations: Always document how the condition affects daily activities, work, or quality of life.

Inadequate Point Documentation: List specific points used (e.g., "LI4, LR3, GB34" not just "acupuncture performed"). Include laterality (bilateral vs unilateral).

No Progress Tracking: Compare current status to baseline and previous visits. Show trends in objective measurements.

Generic Treatment Plans: Explain why you selected specific points and techniques based on TCM diagnosis, not just "standard protocol for back pain."

Missing Medical Necessity: Document why treatment should continue. What hasn't been achieved yet? What would happen without continued care?

Incomplete TCM Diagnosis: Include both Western diagnosis (for ICD-10 coding) and TCM pattern differentiation (Kidney deficiency, Qi stagnation, etc.).

No Treatment Timeline: Establish expected duration and frequency upfront, then document adherence to or adjustment of that plan.

Additional Tips for Insurance-Compliant Documentation

Use ICD-10 Codes Appropriately: Include relevant diagnosis codes that support medical necessity for acupuncture treatment.

Document Treatment Modifications: If you change your approach, explain why based on patient response or lack of progress.

Include Patient Compliance Notes: Document whether patient followed previous home care recommendations and how this affected outcomes.

Photograph Findings When Relevant: For cupping marks, gua sha, or tongue diagnosis, photos can supplement written documentation.

Track Treatment Response Over Time: Create a clear narrative showing how patient progressed from initial visit through current session.

Address Insurance-Specific Requirements: Some insurers require specific language or documentation elements—familiarize yourself with common requirements.

Final Thoughts

Acupuncture SOAP notes don't need to be overwhelming or time-consuming.

They need to be thorough and compliant, yes, but they don't need to consume your life or keep you at the clinic long after your last patient leaves.

The key is having a system that captures the right information—the clinical findings, progress measurements, and treatment rationale that insurance companies require—without making you feel like a secretary instead of a healing practitioner.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear, compliant documentation that supports your clinical judgment and demonstrates the value of acupuncture treatment.

Your time is better spent with your patients, refining your diagnostic skills, and providing excellent care than fighting with documentation templates.

That's exactly why we built this tool—to give acupuncturists back their time while maintaining the documentation standards that insurance companies demand.

Try it out, see how much time you reclaim, and let me know what you think.

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Ready to simplify your acupuncture documentation and get insurance-ready notes in minutes?
Visit soapnotes.doctor and generate your first compliant SOAP notes today.