SOAP notes and OMT coding
The SOAP note
| Part | Contains |
|---|---|
| Subjective | Symptoms, timeline, what makes them better or worse, relevant history, medications, allergies, the patient's goals |
| Objective | Vital signs, exam findings, relevant results, functional measures, and TART findings by region |
| Assessment | Medical diagnoses or differential, plus the somatic dysfunction diagnoses when OMT is planned |
| Plan | Tests, treatment, education, referrals, and when to reassess, tied to the assessment |
For the procedure itself, record the consent discussion, the regions treated and technique classes used, how the patient tolerated it, the response, and the instructions given. A recheck can show improvement, no change or worsening: write what actually happened. No routine extra water or special diet is needed to "flush toxins" after OMT.
The rest of this guide is for founders
Founders get every guide, endless cases with an AI tutor, and Anki export of their misses. Here is what is inside:
- The SOAP note
- The ten regions and their codes
- OMT procedure codes
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