Acupuncture/Dry Needling Treatment Procedure Note

Date of Service: [Date and start time] (Required)

Location: [Clinic/facility/room]

Clinician: [Name, credentials] (Required)

Patient: [Full name and identifier per local policy]

Visit Type: [Acupuncture Treatment / Dry Needling / Acupuncture + Dry Needling]

Relevant Precautions: [Known risk factors such as anticoagulant use, pregnancy, implanted devices, infection risk, vasovagal history, other] (Use "None known" if explicitly screened negative; omit if not applicable)

Indication & Goals

[Primary symptom or condition being treated] [Working diagnosis or problem statement] [Specific objectives for today's session] (1–3 sentences. Include interval context such as response to prior session only if stated. Do not infer diagnosis from treated sites alone.)

Pre-Procedure Safety & Consent

• Safety Screen: [Contraindication screening results] (Document relevant positives; use "denies" or "no known" for items screened negative: bleeding risk/anticoagulants, infection concerns, pregnancy status if relevant to treated regions, implanted electrical devices if e-stim planned, needle sensitivity/vasovagal history, high-risk anatomy such as thorax/neck.)
• Informed Consent: [Consent documentation] (Risks, benefits, alternatives discussed; opportunity for questions provided; patient agreed to proceed. Note if written consent on file.)
• Verification: [Correct patient, procedure, and treatment sites/sides confirmed]

Procedure Details

Patient Position: [Supine / Prone / Seated / Side-lying / Other]

Skin Preparation: [Prep method and site preparation]

Clean Technique: [Hand hygiene performed; sterile single-use needles; clean field maintained; sharps disposed in approved container]

Body Regions Treated: [Regions treated]

Needle Count: Inserted: [Total number] | Removed: [Total number] (REQUIRED: Counts must match. If mismatch, document reconciliation steps and outcome.)

Acupuncture Details

(Include only if acupuncture was performed; omit entirely if not.)

• [Region/Area]:
  • [Point code or anatomical description] ([R / L / Bilateral / Midline])
  • [Additional points as needed]
• [Additional Region/Area]:
  • [Point code or anatomical description] ([R / L / Bilateral / Midline])

Needle Retention Time: [Minutes]

Manual Stimulation: [Yes / No] (If yes, describe technique briefly.)

Electroacupuncture / E-Stim Details

(Include only if electrical stimulation was used; omit entirely if not.)

• Connections: [Points or muscles connected; specify laterality]
• Settings: [Frequency in Hz] [Waveform if known] [Intensity as tolerated]
• Duration: [Minutes]
• Tolerance: [Patient tolerated stimulation at applied intensity / other]

Dry Needling Details

(Include only if dry needling was performed; omit entirely if not.)

• Muscles Treated:
  • [Muscle name] ([R / L / Bilateral]) – [Superficial / Deep], [Static / Pistoning]; LTR [sought and observed / sought but not observed / not sought]
  • [Additional muscles as needed]
• Total Muscles Treated: [Number]
• High-Risk Anatomy Notes: [Safety considerations and technique adjustments] (Include only if treating near thorax, neck, or other high-risk areas.)

Patient Response

Tolerance During Procedure: [Tolerated well / Mild discomfort / Requested pause / Vasovagal symptoms / Other]

Immediate Symptom Response: [Patient-reported and/or observed change] (Include pre/post pain scores 0–10 or ROM changes if measured. Document neutrally if no immediate change.)

Complications/Adverse Events

[None / Description of adverse event] (REQUIRED: Must document explicitly. If event occurred, include: event type, severity, timing, management steps, patient status at departure, and any escalation or referral.)

Post-Procedure Instructions

[Instructions provided] (Include expected effects such as temporary soreness, possible bruising, fatigue; activity guidance; and safety-net instructions for urgent evaluation: chest pain, shortness of breath, fainting, progressive swelling/redness, fever, or neurologic symptoms.)

Plan

• Treatment Frequency: [Recommended frequency and duration, e.g., 1–2x/week for 4 weeks]
• Response Criteria: [Criteria for continuation, modification, or discontinuation]
• Coordination: [Other therapies, home exercises, or referrals as applicable]
• Follow-Up: [Next appointment timing and plan]

Authentication

Clinician Signature: [Name, credentials, date/time] (Required)

(Meta-instructions: Safety-critical fields that must not be omitted: Indication & Goals, Consent documentation, Laterality for all treated sites, Needle Count inserted and removed, Complications/Adverse Events, Plan, and Clinician Signature. If information is unavailable, insert placeholder "REQUIRED: [field name] not documented." For conditional sections—Acupuncture Details, Electroacupuncture/E-Stim Details, Dry Needling Details—omit the entire section if that modality was not performed.)