Acupuncture Re-evaluation/Progress Update Note

Date of Service: [Date of service]

Patient: [Patient name / identifier]

Rendering Provider: [Provider name, credentials]

Visit Number: [current visit] of [total visits this episode]

Interval Covered: Visits #[start] through #[end]

Condition(s) Treated: [Condition(s) / region(s) addressed this episode]

Interval Summary and Subjective

[Reason for reassessment and trajectory] (Open with 1–2 sentences stating whether this is a scheduled interval reassessment or prompted by clinical change, date of last evaluation, and overall trajectory as [improved / unchanged / worse / mixed].)

[Patient-reported response] (Summarize symptom changes including intensity, frequency, and duration of benefit; functional changes in ADLs, work, sleep, or activity; and response pattern to treatments. Include interval medical changes such as new diagnoses, medication changes, or imaging only if reported.)

[Adverse effects] (Document specifics from prior sessions or state none reported.)

[Patient-reported outcome measures] (Include instrument name and score only if collected this interval.)

Objective

Examination: [Focused physical findings relevant to treated condition] (Include palpation, tissue findings, ROM with measurements, and neurologic screening as clinically indicated.)

Outcome Measure Comparison: [Instrument name]: Baseline [score] → Last reassessment [score] → Current [score]; Net change [value] (Include only if available.)

TEAM Findings: [Tongue, pulse, pattern updates] (Include only when actively informing treatment decisions.)

Assessment

[Condition/region]: [improved / partially improved / unchanged / worse] — [Evidence supporting status] (Cite at least one measurable change such as pain scale or PRO score, plus one clinical observation such as ROM or palpation finding. Briefly interpret the clinical significance.)

(Repeat for additional conditions if multiple problems are being treated.)

Goal Status:

• [Goal] — [met / partially met / not met / revised] (Brief comment; include rationale for any revision.)

[Medical necessity statement] (Include concise justification for continued skilled acupuncture care only when billing or policy requires.)

Plan

Plan of Care Decision: [continue current plan / modify plan / taper to maintenance / discharge]

Frequency/Duration: [e.g., 1x/week x 4 weeks]

Clinical Focus: [Primary treatment targets and any changes to approach]

Patient Education and Home Program: [Topics covered, self-management strategies, exercises, or lifestyle recommendations]

Coordination of Care: [Referrals or communication with other providers] (Include only if indicated.)

Next Reassessment: [Timing or criteria, e.g., in 4 visits or sooner if specific milestones or setbacks occur]

(If same-day treatment was performed, note: Procedure documented in separate note.)

Procedure

(Include this section only if the acupuncture procedure is documented within this note rather than separately.)

Consent: [Informed consent status]

Needling Summary: [Style/technique, regions/points treated, retention time, adjuncts if used] (Note aseptic technique.)

Patient Response: [Tolerance and immediate effects]

Complications: [None / describe]