Documentation guide
Health coaching SOAP note template for Medicare
How to write a SOAP-style note for health and well-being coaching sessions billed under 0591T, 0592T and 0593T: what goes in each section, the fields you can't skip, and a worked example.
Short answer
A health coaching SOAP note records what the patient reported (S), the facts of the encounter (O), progress within coaching scope (A), and the next steps (P). For Medicare coaching, every note should also show actual start and stop times, the modality, the link to the supervising practitioner's plan of care, the coach's name and credential, and the supervising practitioner. The final rule lists no coaching-specific documentation elements, so these are best practices. Your supervising practitioner's and organization's policies come first.
Before you write: a 30-second checklist
- Is there a practitioner order or plan of care this session carries out?
- Did you record the actual start and stop times, not an estimate?
- Is every statement about this patient in this session, with nothing copied forward?
- Did any new clinical concern get routed to the practitioner?
- Are you, the credential, and the supervising practitioner named?
What belongs in each section
S: Subjective (goals, readiness, barriers)
The patient's own words and reports: what matters to them, their goals, how ready and confident they feel, what got in the way since last time, and what helped. Quote briefly where it adds meaning ("I want to walk with my grandkids").
O: Objective (encounter facts and coaching delivered)
Facts anyone could verify: date, actual start and stop times, modality (in person, audio-video, audio-only), tools used (readiness ruler, goal worksheet), patient-tracked data reviewed (step log, food diary), and the coaching approaches used, such as motivational interviewing or action planning. For groups, the topic and attendance.
A: Assessment (progress within coaching scope)
A short coaching judgment: progress toward the patient's goals and the practitioner's plan, current readiness, barriers, and what that means for the coaching. Coaches do not diagnose, assess disease, or write unsupported medical-necessity statements.
P: Plan (SMART actions, follow-up, escalation)
The specific actions the patient chose (specific, measurable, achievable, relevant, time-bound), the next session, and any referral back to the supervising practitioner, with the reason.
Adapt the note to the encounter
| Code | Emphasize |
|---|---|
| 0591T initial assessment | Values and what matters to the patient, readiness and confidence, baseline behaviors, first goals, and the link to the practitioner's order. |
| 0592T follow-up (at least 30 min) | Progress on each existing goal, barriers since last session, goal adjustments, and actual time meeting the 30-minute descriptor. |
| 0593T group (2+, at least 30 min) | A group record (topic, total time, roster) plus an individualized entry for each billed beneficiary. |
Must-contain vs should-contain fields
| Must contain | Should contain |
|---|---|
| Date, actual start and stop times | Total minutes |
| Modality (in person, audio-video, audio-only) | Tools or worksheets used |
| Condition or goal from the practitioner's plan of care | A sentence linking the session to that plan |
| Patient-specific goals and progress | Patient-reported measures (steps, servings, sleep) |
| Next steps and follow-up date | Barriers and supports |
| Referrals of new clinical issues to the practitioner | The reason for the referral |
| Coach name, credential and signature; supervising practitioner named | Periodic practitioner review noted |
| Groups: individualized entry per beneficiary | Groups: number of participants |
This field list reflects general incident-to and time-based documentation practice, not a CMS coaching checklist. Adapt it to your organization's policies and EHR, and recheck it when your MAC publishes guidance.
Fictional SOAP note example (0592T follow-up)
Date: [date] · Time: [actual start]–[actual stop] · Modality: audio-video · Order/plan: Dr. [name], [date], coaching for [condition from plan]
S: "I did the walks on my work days but not weekends." Walked 4 of 6 planned days. Confidence 6/10 (was 5/10). Weekend family events are the main barrier.
O: Step log reviewed: weekday average about 5,000 steps. Used motivational interviewing and action planning. Weekend scenario planned with the patient.
A: Progressing toward the walking goal in the practitioner's plan. Weekday routine established; weekends are the gap. No new clinical concerns reported.
P: Patient will take a 15-minute family walk after Saturday lunch. Keep weekday walks. Follow-up in 2 weeks. Coach: [name, credential, signature]. Supervising practitioner: [name].
How to read the example
- The S section uses the patient's words and numbers they reported.
- The O section is verifiable: time, modality, data reviewed, techniques used.
- The A section judges progress against the practitioner's plan, with no diagnosis.
- The P section is a patient-chosen, measurable action plus the follow-up date.
- Bracketed fields are placeholders. Never pre-fill times, medical-necessity language or outcomes.
Common documentation mistakes
- Copy-forward notes. Text carried from the last session without editing looks cloned, and cloned notes are a known audit concern.
- Estimated or default times. Record what actually happened.
- One note for a whole group. 0593T is billed per beneficiary, so each needs an individualized entry.
- Clinical language out of scope. "Patient's diabetes is improving" is a clinical assessment. "Patient reports walking 4 days this week toward the activity goal in Dr. [name]'s plan" is coaching.
- No link to the plan of care. The note should show the coaching carries out the practitioner's plan.
- Unrouted concerns. New symptoms, medication questions or safety concerns that were noted but never sent to the practitioner.
Use templates as prompts, not substitutes for judgment
A good template reminds you which fields to complete. It should never supply the content. Your supervising practitioner's and organization's documentation policies come first, and those policies must comply with CMS, your MAC and state law. If anything conflicts, stop and ask your compliance officer before billing.
Frequently asked questions
Do Medicare health coaching codes have specific SOAP note requirements?
No. The CY 2027 final rule's coaching section lists no coaching-specific documentation elements. Follow general documentation practice and the requirements of your supervising practitioner, organization, CMS, your MAC and state law.
What should a health coach write in the Assessment section?
Progress toward the patient's goals and the practitioner's plan, current readiness or barriers, and what that means for coaching. Not diagnoses or disease assessments.
Can a health coach diagnose or change a treatment plan in a SOAP note?
No. Coaches document within scope and route new clinical concerns or treatment questions to the supervising practitioner.
How do you document a group health coaching session?
Record the topic, modality, date, start and stop times, facilitator and attendance, then write an individualized entry for each beneficiary. See 0593T group coaching.
Educational only. Not legal, billing, coding or clinical advice. CPT® is a registered trademark of the American Medical Association; descriptors are paraphrased.