Session Notes (SOAP)

Internal documentation for Rob's own records.

Internal Use Only

This template follows the general documentation elements referenced in VA Community Care provider guidance — diagnosis (ICD-10) and procedure (CPT/HCPCS) coding, referring provider, modality and time, and functional status/progress. Requirements can vary by contract or Third Party Administrator (Optum/TriWest), so it's worth double-checking this against the terms of your specific VA agreement.

Session Information

Client / Veteran Name

Date of Birth

Date of Service

Session Length (min)

VA Authorization / Referral #If applicable

Referring VA Provider / Clinic

Diagnosis & Billing Codes

ICD-10 Code(s) / Reason for Visit

CPT / HCPCS Code(s)

SOAP Note

SSubjectiveClient-reported symptoms, complaints, and changes since the last visit

OObjectiveObservations, palpation findings, posture, range of motion, tissue quality

AAssessmentClinical interpretation, functional status, progress toward goals

PPlanTechniques used this session, home recommendations, plan for next visit

Provider Sign-Off

Provider Name

NPI / License Number

Signature (type full name)

Date Signed

This note is sent directly to Rooted Manual Therapy's private email and is not shared elsewhere.

Note Submitted

The session note has been recorded.