Documentation Templates
Clinical records, SOAP notes, and treatment log templates
Last updated: March 14, 2026
Thorough clinical documentation serves dual purposes: ensuring continuity of care and providing legal protection in the event of an adverse outcome. These templates are derived from published surgical guidelines (Mumcuoglu et al., 2014; Abdualkader et al., 2013) and adapted for both hospital and outpatient settings.
Pre-Treatment Record
Template Fields
- Signed informed consent (original in medical record)
- Contraindication screening completed and documented
- Clinical indication with supporting diagnosis
- ICD-10 codes for billing
- Baseline labs: CBC, PT/INR, aPTT, BMP
- Antibiotic prophylaxis: Drug, dose, route, start date
- Baseline photographs under standardized lighting
- Leech source: Manufacturer, lot number
Per-Session SOAP Note
SOAP Format
S — Subjective
Patient-reported pain level (NRS 0-10), symptoms since last session, medication compliance (antibiotics taken as prescribed), any adverse effects (itching, drainage, fever).
O — Objective
Vital signs (pre and post). Tissue assessment: color, capillary refill, Doppler signal, temperature, turgor. Wound status: prior bite sites (healed/oozing/infected). Lab values if obtained. Number of leeches applied, anatomic location(s) (diagram), attachment duration per leech, post-detachment bleeding duration and estimated volume.
A — Assessment
Clinical impression: tissue improving/stable/worsening. Response to current session. Any complications or concerns. Comparison with baseline photographs.
P — Plan
Next session timing. Modification to number of leeches or application sites. Lab orders for next session. Antibiotic prophylaxis continuation plan. Patient instructions for wound care and return precautions. Follow-up appointment scheduled.
Per-Session Treatment Log
Session Documentation Fields
| Field | Details |
|---|---|
| Date & time | Start and end of session |
| Session number | Sequential (e.g., 3 of 7) |
| Number of leeches | Applied this session |
| Anatomic sites | Diagram or description |
| Attachment duration | Per leech (minutes) |
| Post-detachment bleeding | Duration (hours), estimated volume (mL) |
| Vital signs | Pre and post session |
| Tissue assessment | Color, capillary refill, Doppler, temperature |
| Patient tolerance | Pain score, adverse reactions |
| Leech disposal | Confirmed biohazard waste |
| Clinician signature | Practitioner and/or RN |
Post-Treatment Summary
Course Completion Record
- Total sessions completed and dates
- Total leeches used across all sessions
- Cumulative estimated blood loss
- Post-course labs: CBC, hematocrit
- Antibiotic prophylaxis plan: Continue 24-48h after last session
- Clinical outcome assessment: Tissue status, symptom resolution
- Serial photographs: Baseline through completion
- Adverse events: Any complications and management
- Follow-up schedule: 24h, 72h, 1 week, 2 weeks, 4 weeks
- Infection surveillance period: 26 days post-final session
Clinical Photography Standards
Documentation Photography
- Standardized lighting and angle for each session
- Include ruler or measurement reference in frame
- Photograph before, during (with leeches attached), and after each session
- Date and patient ID visible (or linked in record)
- Consistent camera distance and positioning
- Photographs support both clinical decision-making and reimbursement appeals