Acupuncture Plan of Care

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number] (Include only if used in this setting)

Date of Plan: [Date]

Document Type: [Initial Plan / Revised Plan] (If Revised Plan, include revision date and reason for revision)

Practice Location: [Clinic name and address]

Clinician: [Name, credentials, license number, NPI]

Referring Clinician: [Referring clinician name and credentials] (Include only if patient was referred)

Referral Date: [Date] (Include only if patient was referred)

Reason for Care

[Primary reason for acupuncture care, body region(s) or condition(s) being addressed, and clinical context (acute flare, subacute episode, chronic management). Note any conditions explicitly outside the scope of this plan.] (1–3 concise sentences)

Diagnoses

• [Diagnosis name] — Status: [working / confirmed / rule-out / history of]; ICD-10: [Code] (Include ICD-10 only if used in this clinical environment)
• [Additional diagnoses as needed, in order of clinical priority]

TCM Pattern Assessment: [Pattern(s) and supporting findings; how this informs point selection and patient counseling] (Include only if TCM assessment is actively used to guide treatment; omit entirely if not performed)

Baseline Status

• Pain intensity: [Region(s), scale used (e.g., 0–10), baseline rating(s)]
• Functional measures: [Measurable functional limitations with baseline values (e.g., standing tolerance, walking distance, sleep quality, work/leisure participation)]
• Patient-reported outcome measures: [Instrument name(s) and baseline score(s)] (If not yet collected, state the plan to collect and intended instrument(s))
• Key clinical findings: [Pertinent examination findings guiding treatment targeting or safety precautions]
• Safety screening: [Relevant findings: bleeding risk/anticoagulants, pregnancy status, implanted electrical devices, skin integrity, vasovagal history, other risks pertinent to needling or planned electroacupuncture]

Goals

Patient-stated goals: "[Patient's own words]" (Include when documented)

Short-Term Goals (2–4 weeks):

• STG ([Timeframe]): [Metric] — Baseline: [value]; Target: [value]

Long-Term Goals (episode of care):

• LTG ([Timeframe]): [Metric and functional participation target] — Baseline: [value]; Target: [value]

Treatment Plan

• Acupuncture style/techniques: [body acupuncture / auricular / scalp / trigger point-informed / other]
• Point selection strategy: [General regions/meridians and rationale; local, distal, and systemic strategies as applicable]
• Needle technique parameters: [Depth approach; stimulation method; retention time range]
• Patient positioning: [supine / prone / side-lying / seated]
• Electroacupuncture: [Target regions and parameter framework (frequency, waveform, intensity approach); contraindication screening completed] (Include only if planned)
• Adjunct modalities: [cupping / gua sha / moxibustion / heat therapy] — [Brief rationale] (Include only if planned)
• Home program: [Self-acupressure, mobility/stretching, lifestyle guidance] (Include only if prescribed)
• Progression/adaptation plan: [How treatment will be modified based on patient response, tolerance, or evolving goals]

Visit Schedule

• Frequency: [Visits per week or month]
• Session duration: [Typical minutes]
• Planned episode duration: [Number of weeks]
• Anticipated total visits: [Number or range with rationale] (If cannot estimate, define trial period with reassessment)
• Reassessment schedule: [When and which outcomes will be re-measured]

Continuation and Discontinuation Criteria

• Continue treatment when: [Measurable improvement toward goals; tolerable side effects; adequate adherence]
• Modify plan when: [Partial response, plateau, tolerance issues, adherence barriers, new clinical information]
• Discontinue when: [Goals achieved, lack of measurable benefit after defined trial, regression, unacceptable adverse effects, patient preference, new contraindications]

Care Coordination

Other treating clinicians: [Clinician names, specialties, and roles] (If none, state "No other clinicians currently involved in treatment of this condition")

• Communication plan: [Information to share, method, and timing]
• Escalation/referral triggers: [Red flags, new neurological deficits, lack of progress by reassessment date, need for imaging/labs or specialty consultation]

Consent and Safety

[Document informed consent obtained: diagnosis discussed, nature/purpose of acupuncture, benefits, risks emphasized based on treatment regions, alternatives, patient questions addressed, patient decision to proceed.] Sterile single-use needles and safe technique will be used. Patient instructed to contact clinic if [concerning symptoms to monitor for] occur following treatment.

Signature

Clinician Signature: ________________________________

Printed Name and Credentials: [Clinician name and credentials]

Date/Time: [Date and time signed]

(Do not fabricate content. If information was not obtained or does not apply, omit the element or document the plan to collect it. Working diagnoses are acceptable when evaluation is incomplete but must be labeled as such.)