EL – Acupuncture

[checkbox name="historian" value="New patient, consent signed|Existing patient|SO/family member present during visit|Chaperon/MA present during visit||Interpretation provided by family member/SO|Interpretation provided by MA||Complete history unobtainable d/t poor effort/affect|Complete history unobtainable d/t lack of knowledge|Complete history unobtainable d/t language barier"]
CC: [textarea name="variable_2"]
MEDICAL HISTORY: [checkbox name="PMH" value="worse at night|worse with movement|worse with twisting|h/o surgery|anticoagulation|"][textarea name="variable_3"]
TCM PATTERN: [checkbox name="tcm" value="Deficiency|Excess|Qi stagnation|Qi deficiency|Xue stagnation|Xue deficiency|Yin deficiency|Yang deficiency|Dampness|Heat|Cold|Dryness|Wind|"][textarea name="variable_5"]
O: [checkbox name="objective" value="deformity|muscle spasm|hypertonisity|visible swelling|active trigger points|color changes|scoliosis|"][textarea name="variable_6"]
A: [textarea name="variable_7"]
TREATMENT: Procedure, potential SE, R/B/A, aftercare explained. Patient verbalized understanding & agreed w POC
Positioned: [checkbox name="position" value="Supine on table|Prone on table|Seated in massage chair face down|Seated in office chair leaning back|Seated on stool leaning against desktop massage system|"]
Treatment points localized based on TCM pattern, direct tenderness, local twitch response, and radiation patterns
[text]
Main Modality: [checkbox name="modality" value="Acupuncture (dry needling) w/o electrostimulation|Acupuncture (dry needling) w/ electrostimulation"]
Skin prepped with alcohol prior to needle insertion, treated: [text][checkbox name="points" value="points along GV channel|suboccipital points|trapezious muscle|levator scapula|points around scapula|points along inner BL line|points along outer BL line|QL|"][textarea name="variable_10"]
Needles retained for 8 to 15 minutes, removed (counted) [text] intact needles
Additional Modalities: [checkbox name="additional" value="manual pressure|cupping (vasopneumatic device)|stretching|"][text]
Reported [checkbox name="reported" value="decrease|increase|no change"] in pain/symptoms
[text]
VERBALLY INSTRUCTED ON: [checkbox name="instructions" value="Exam findings/Treatment provided|Recommendations|ROM exercise/stretching to prevent deconditioning|Appropriate follow up|When and how to report possible side effects|When to contact emergency services"][text]
BARRIERS TO CARE: [checkbox name="barriers" value="None identified|Multiple comorbidities|Chronicity of condition|Lack of motivation|Incomplete history|Vague shifting complaints|Intolerance of multiple meds and/or treatments|Social/cultural barriers|Preoccupation with illness|Catastrophization|Unrealistic beliefs"][text]
DISPOSITION: Tolerated procedure well and no complications were noted or reported. Condition stable. Discharged home. [checkbox name="disposition" value="RTC as discussed, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx|Referred to ER for immediate treatment via 911|Referred to ER for immediate treatment via private transport|Declined emergency transfer|Left facility before being discharged|Refered to medical department|"][text]
FURTHER CARE: [checkbox name="further" value="Continue with current treatment plan|Follow up in one week|Change frequency of visits to PRN|Change treatment plan|Released from care, max improvement reached|Released from acupuncture d/t poor/aberrant response to treatment"]

CC:

MEDICAL HISTORY:

TCM PATTERN:

O:

A:

TREATMENT: Procedure, potential SE, R/B/A, aftercare explained. Patient verbalized understanding & agreed w POC
Positioned:
Treatment points localized based on TCM pattern, direct tenderness, local twitch response, and radiation patterns

Main Modality:
Skin prepped with alcohol prior to needle insertion, treated:

Needles retained for 8 to 15 minutes, removed (counted) intact needles
Additional Modalities:
Reported in pain/symptoms

VERBALLY INSTRUCTED ON:
BARRIERS TO CARE:
DISPOSITION: Tolerated procedure well and no complications were noted or reported. Condition stable. Discharged home.
FURTHER CARE:

Result - Copy and paste this output:

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