Adverse Event/Complication Note (Acupuncture and Adjunct Therapies)

Date/Time Authored: [Date and time with time zone]

Author: [Name, credentials, role]

Encounter Context: [in-clinic during session / post-visit call / follow-up visit]

Location: [Clinic/site name]

Event Summary

[1–3 sentence plain-language synopsis of what happened, when and where it occurred, and the patient's current status] (Use "temporally associated with" rather than causal language.)

Event Type: [vasovagal/presyncope/syncope / burn/thermal injury / prolonged/worsening pain / bleeding/hematoma / needle site reaction / suspected infection / suspected allergic reaction / retained/stuck/broken needle / suspected pneumothorax or organ injury / cupping-related skin lesion / electroacupuncture issue / other]

Severity: [Mild - no escalation, resolves quickly / Moderate - prolonged observation, treatment change, next-day follow-up / Severe - EMS/ED transfer, hospitalization, potential permanent harm]

Disposition: [returned to baseline / improved / unchanged / worsened / transferred to higher level of care]

Context and Treatment

• Relevant history and risk factors: [Pertinent medical history related to this event]
• Medications: [Current medications, especially anticoagulants, sedatives, hypoglycemics] (If none, state none reported.)
• Allergies/sensitivities: [Drug, topical, herb, supplement, smoke/scent sensitivities] (If unknown, state unknown.)
• Pre-procedure status: [Fasting/hydration status, baseline symptoms, positioning, first-time exposure to modality] (Include only if relevant to event.)
• Therapies performed: [Modalities used, body regions treated, key parameters] (Reference full treatment note; include enough detail to evaluate event independently.)
• Modality-specific details: [Details pertinent to this event type, e.g., needle count inserted/removed if retention concern; moxa type and safety measures if burn; cupping type/duration if skin injury; product name/lot/dose if supplement reaction] (If product information unknown, note this and document plan to obtain.)
• Key timing anchors: [Treatment start], [event recognized], [treatment stopped], [first intervention], [recovery/transfer] (Use absolute times; label approximations.)

Timeline Narrative

(Provide factual, time-stamped chronology using absolute and relative times. Include brief patient quotes when clarifying onset or severity. Label uncertainties explicitly. This is the core medicolegal section.)

• [Time — Pre-event baseline] [Patient appearance, relevant baseline vitals, initial status]
• [Time — Event onset] [Patient-reported symptoms; objective observations such as pallor, diaphoresis, altered responsiveness, visible injury, bleeding]
• [Time — Immediate actions] [Therapy stopped, needles removed, positioning, local care, other interventions]
• [Time — Subsequent events] [Patient response, reassessments, additional interventions, consultations]
• [Time — Discharge/transfer] [Condition at exit, transport details, instructions provided]

Assessment

• Vitals: [At baseline, symptom onset, post-intervention, and discharge/transfer as applicable] (If not obtained, state reason.)
• Focused exam: [Pertinent positives and negatives targeted to event type] (Document only what was performed.)
• Clinical impression: [Working diagnosis, severity, current stability, differential if needed] (Use "temporally associated with" for relationship to therapy; use "suspected" or "cannot rule out" for uncertain diagnoses.)

Plan

• Management provided: [Treatments performed and patient response]
• Patient communication: [Who was informed, what was explained, understanding confirmed]
• Instructions and return precautions: [Specific home care, event-appropriate red flags requiring urgent/ED care]
• Product/device actions: [Products or devices discontinued/held and duration] (If applicable.)
• Follow-up: [Modality and specific timeframe] (Avoid vague PRN for moderate/severe events.)
• Referrals: [ED/EMS/urgent care/PCP/specialist with rationale] (If applicable.)
• Reporting: [Supervisor notification, internal incident report, external reporting such as FDA MedWatch] (State completed or planned; do not include root-cause analysis.)
• If patient declines recommended escalation: [Capacity assessment, risks explained, alternatives offered, patient's stated reason, refusal documentation completed]

Signature: [Name, credentials, role, date/time]

Addendum: [Later-obtained information with date/time and source attribution] (Do not overwrite prior content; add as new entry when ED results, follow-up findings, or other information becomes available.)