Adverse Event/Incident Note (Acupuncture)

Date/Time of Event: [Event recognition date/time; resolution date/time if different] (Use local time; include "approximately" if exact time unknown.)

Author: [Name and credentials]

Location: [Clinic name and room]

Event Summary

[1–3 sentence abstract summarizing indication for acupuncture, the adverse event that occurred and when, immediate actions taken, and outcome/disposition] (Use only facts known at the time; omit speculation or process commentary.)

Treatment Context

(Document concise pre-event background necessary to understand the event.)

• Indication for treatment: [Primary reason for visit]
• Baseline symptoms relevant to event: [e.g., dizziness, easy bruising, neuropathy, chest discomfort history] (Only include if pertinent to the event.)
• Risk factors: [Anticoagulant/antiplatelet use / bleeding disorder / diabetes or neuropathy / pulmonary history / relevant allergies / none known]
• Consent status: [Verbal consent obtained / Written consent obtained / Consent on file]
• Patient position at start: [supine / prone / lateral decubitus / seated]
• Needle count inserted: [Total number]
• Needle sizes/lengths used: [Gauge and length ranges]
• Points/regions treated: [List points/regions] (Specify thoracic/neck/scapular regions if chest symptoms occurred.)
• Adjunct modalities: [none / electroacupuncture / moxibustion / heat lamp / cupping / gua sha / other]
• Intra-procedure notes prior to event: [Any unusual observations or patient statements prior to the event] (Omit if none.)

Adverse Event Timeline

(Time-stamped chronological reconstruction. Use "approximately" if exact times unknown. Use direct quotes for key patient statements. Avoid causal conclusions or language implying fault.)

• [Time]: [Patient-reported symptoms using direct quotes] | [Observed signs/appearance] | [Context: needles in/out, modality active, patient position] | [Who present and actions taken] | [Procedure status: continued / paused / stopped]
• [Time]: [Subsequent development] | [Actions taken] | [Patient response]
• [Time]: [Status at resolution/transfer] | [Actions taken] | [Outcome]

Objective Assessment

• Vital signs with times: [BP, HR, RR, SpO2 with timestamps] (If not obtained, document why.)
• Focused exam findings: [Event-specific physical exam] (For vasovagal/syncope: mental status, skin signs, recovery course. For bleeding/hematoma: site exam, hematoma size in cm, distal neurovascular status. For burns: location, size in cm, depth estimate, blistering, surrounding erythema. For chest symptoms: work of breathing, ability to speak full sentences, breath sounds if within scope, SpO2, progressive vs stable. Include only assessed findings.)
• Needle count reconciliation: Inserted: [X]; Removed: [Y] (Note any concerns about missing or broken needles and actions taken.)
• Photos: [Taken with consent / Not taken] (If taken, note storage location.)

Immediate Management

(Document interventions with timestamps and reassessment findings after each. Include only applicable items.)

• [Time]: Treatment stopped; all needles removed
• [Time]: [Positioning adjustments: supine / leg elevation / lateral position]
• [Time]: [Bleeding control measures: pressure duration, dressing type]
• [Time]: [Burn first aid: cooling method/duration, dressing type]
• [Time]: [Monitoring/reassessment: vital signs, mental status, symptom trajectory]
• [Time]: [EMS activation with rationale]
• [Time]: [Consultation/referral call: who contacted, guidance received]

Event-specific details (Include one section based on event type):

• Vasovagal/syncope: [Trigger context] | [Duration of syncope if any] | [Observation period] | [Return to baseline confirmation] | [Disposition safeguards]
• Bleeding/hematoma: [Estimated quantity] | [Time and method of pressure] | [Hemostasis outcome] | [Anticoagulant status]
• Burn: [Heat modality type and parameters] | [Circumstances] | [Immediate cooling method/duration] | [Dressing applied]
• Suspected pneumothorax: [Symptom onset timing relative to needling] | [Thoracic points needled with needle length/depth] | [Serial SpO2/RR] | [EMS activation rationale]

Patient Counseling & Disclosure

• Explanation provided: [What was explained about the event, including clinical uncertainties]
• Patient questions and answers: [Summary of key questions and responses]
• Red-flag return precautions: [Explicit ED/911 triggers tailored to event type]
• Written instructions provided: [yes / no]
• Refusal of recommended care: [Capacity indicators] | [Recommendation made] | [Risks discussed] | [Patient's stated reason] | [Alternative plan] | [Strict return precautions] (Only include if patient refused recommended ED/EMS evaluation.)

Disposition & Follow-Up

• Disposition: [Observed in clinic until baseline / Discharged with escort / Transferred by EMS / Advised ED but declined]
• Follow-up plan: [Specific timeframe for scheduled appointment or phone check-in]
• Activity restrictions: [Restrictions if applicable] (Omit if none.)
• Care coordination: [PCP/specialist notified; records sent] (Omit if not applicable.)
• Closed-loop plan: [Who will contact whom and when]

Addendum

(Add only if new information becomes available after initial note. Do not overwrite prior entries.)

• Addendum Date/Time: [Date/time]
• New information: [Details received]
• Actions taken: [Follow-up actions, referrals, contact attempts]

Electronic Signature: [Author name and credentials]

Date/Time Signed: [Date/time]