SOAP Notes

Outpatient Osteopathic SOAP Note Form Series

Excerpt from a SOAP noteThe AAO developed the Outpatient Osteopathic SOAP Note Form Series to provide a consistent method of recording the findings of musculoskeletal examinations. According to a study published in The Journal of the American Osteopathic Association in 1999, completed Outpatient Osteopathic SOAP Note Forms contained more comprehensive information than the physician’s progress notes. In addition, these SOAP Notes include information not previously recorded, such as details of detected somatic dysfunctions.

The American Academy of Osteopathy’s Louisa Burns Osteopathic Research Committee (LBORC) developed the Outpatient Osteopathic SOAP Note Form Series as part of a grant from the American Osteopathic Association. These forms are valid, standardized and easy to use. The LBORC highly recommends these forms to the osteopathic medical profession for research and training in osteopathic medicine.

Please send any feedback to LBORC@academyofosteopathy.org.

SOAP NOTE GUIDES and BLANK FORMS

Original SOAP Note Usage Guide
Original Outpatient Osteopathic SOAP Note Form (1-page blank form)
The original note developed by the AAO, this is a good note for a brief follow-up visit after the initial intake. The note is short so some physicians may complain of not enough room to write. Because the coding is abbreviated, other notes may be better for beginners to train on how to do coding and billing.

Outpatient Osteopathic SOAP Note Form Series Usage Guide
Outpatient Osteopathic SOAP Note Forms (4-page blank form)
The Outpatient Osteopathic SOAP Note Form Series is a four-page note that is ideal for use as a new patient initial exam for a general medical visit. It contains a Health Summary page for a detailed history and plenty of space to write exam findings in addition to the somatic dysfunction table. This is a great resource for learning how to code and bill a visit.

Inpatient Osteopathic SOAP Note Form (2-page blank form)
The Inpatient Osteopathic SOAP Note Form is designed to be used for inpatients requiring a comprehensive musculoskeletal exam and/or treatment. It also is handy for consultations. There is no usage guide for this form, but details on how to fill it out can be found in the Outpatient Osteopathic Single Organ System Musculoskeletal Form Series.

Outpatient Osteopathic Single Organ System Musculoskeletal SOAP Note Usage Guide
Single Organ System Musculoskeletal SOAP Note Form (4-page blank form)
The Outpatient Osteopathic Single Organ System (SOS) Musculoskeletal Form is a four-page note designed to be used as a new patient intake form for those patients requiring a comprehensive musculoskeletal exam, comprehensive history (Health Summary Page) and possibly osteopathic manipulative treatment. It also can be used as a follow-up form for those requiring a comprehensive history and/or musculoskeletal exam ongoing, periodically or as a yearly H&P. The coding guidelines in this series are very detailed. This is a good series for training beginners in coding and billing.

Follow-up SOAP Note Usage Guide
Follow-up SOAP Note Form (2-page blank form)

The Follow-up SOAP Note For is a two-page form designed to be used by the physician for follow-up treatment(s) with a patient who has been treated or is currently being treated for somatic dysfunction. This form should only be used for those patients whose history and medical background has previously been documented within the last three years – reference the SOS Musculoskeletal or the Outpatient Osteopathic SOAP Note forms.

Outpatient Cranial SOAP Note Form Usage Guide
Cranial SOAP Note Form (1-page blank form)
The Outpatient Cranial SOAP Note Form is a one-page form designed to be used by osteopathic physicians who primarily perform osteopathic cranial manipulative medicine or those who have a patient with somatic dysfunction in the head region. The Outpatient Cranial SOAP Note Form Usage Guide also presents a short overall explanation for billing and coding of OMT services which is useful for coding and billing on all levels.

SOAP Note Training

The LBORC provides training for osteopathic physicians, residents, interns and students who may be interested in using the Outpatient Osteopathic SOAP Note. If you are interested in this training, please contact Debbie Cole, the AAO’s staff liaison for the LBORC, at DCole@academyofosteopathy.org or at (317) 879-1881, ext. 215.

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