Acupuncture Session Note (Chronic Low Back Pain, Medicare)

Date of Service: [date]

Provider: [name, credentials]

Session: [#] of current course (Course start: [date])

Sessions this 12-month period: [#]/20

Within initial 12 sessions? [Yes / No]

Demonstrating improvement to support continuation? [Yes / No] (Include only if session ≥ 13)

Subjective

[Chief complaint of chronic low back pain]

[Interval response since last session, including immediate and sustained effects on pain, function, and daily activities]

[Adverse effects since last session] (State explicitly if none.)

Current pain intensity: [#]/10

Progress comparison:
Pain: Baseline [#]/10 → Today [#]/10
Function ([specify consistent measure]): Baseline [descriptor] → Today [descriptor]

(Use a single, consistent functional measure for the entire course. If baseline values were not captured at first visit, label current values as "first captured baseline" and note the gap.)

[Changes in analgesic use or concurrent therapies] (Include if applicable.)

[cLBP eligibility statement: pain ≥12 weeks, nonspecific etiology, not associated with surgery or pregnancy] (For session 1: include full eligibility confirmation. For subsequent sessions: include one-line reaffirmation unless clinical status has changed.)

Objective

Exam: [general appearance]; [gait]; [lumbar ROM]; [tenderness/spasm]; [neurologic findings as indicated]

(Include at least one trendable observation each session such as quantified ROM or gait quality. Keep exam focused and repeatable.)

Procedure

Acupuncture for chronic low back pain

• Consent: [confirmed / reaffirmed]
• Position: [prone / supine / side-lying]
• Technique: [manual / with electrical stimulation]
• Points/regions treated: [list]
• Retention time: [minutes]
• Electrical stimulation parameters: [frequency, waveform, intensity] (Include only if electrical stimulation used.)
• Tolerance: [tolerated well / describe issues]
• Complications: [description and management] (Include only if complications occurred; otherwise omit entirely.)

Assessment

[Chronic low back pain status]: [improved / stable / worse] since baseline; [improved / stable / worse] since last session. [Specific pain and functional measure changes supporting this determination]

(For sessions ≥12: explicitly state whether patient is demonstrating improvement with supporting evidence to justify continuation. If not improving, state clearly.)

Plan

• Decision: [Continue / Discontinue] acupuncture. [Brief rationale tied to documented response]
• Next session: [timing/interval]; Reassessment: [what and when]
• Goals: Pain [target]/10; Function [target using same measure]
• Adjunctive care: [home exercise / activity modification / referrals / other] (Include if applicable.)

(If discontinuing for lack of improvement: document alternate care pathway. If approaching coverage limits without improvement: document that Medicare coverage counseling was provided. If session counts unknown due to outside care: note patient-reported counts and that records were requested.)