Asian Bodywork Therapy Procedure Note (Tuina/Acupressure)

Date/Time: [Date] [Start time] [End time if duration clinically relevant or billed]

Patient: [Full name], [DOB or MRN]

Practitioner: [Name], [Credentials]

Location: [Clinic / facility / setting]

Procedure Overview

Procedure: Asian Bodywork Therapy — [Tuina / acupressure / combination]. Indication: [Primary indication or target complaint] (Link to diagnosis when available).

Consent: [Verbal / written] consent obtained after discussion of risks (soreness, bruising), benefits, and alternatives. (If sensitive areas involved: Chaperone [offered / declined / present — name and role]. If consent not obtained, document reason and disposition.)

[Safety considerations that influenced treatment plan: skin integrity, bleeding/bruising risk, fracture risk, pregnancy considerations, red flags screened] (Include only items actually assessed and relevant to this session; omit if none.)

Pre-Procedure Assessment

[Chief concern in patient's words], [Symptom location with laterality], [Severity on consistent scale], [Functional impact].

• [Palpation findings: tenderness, taut bands, tissue tone]
• [ROM limitations: joint, plane, degrees or qualitative description]
• [Postural or movement observations]

(Include only findings actually assessed; omit bullets that do not apply.)

Procedure Details

• Positioning: [supine / prone / side-lying / seated] (Note transitions and supports as used.)
• Adjuncts: [Lubricant type / heat pack / topical liniment / none]
• Regions treated:
  • [Anatomical region with laterality]
  • [Additional regions as treated]
  (Use precise anatomical terms with laterality.)
• Channel/meridian reasoning: [Channel names with laterality] — [Brief rationale] (Include only if channel framework guided treatment.)
• Manual techniques:
  • [Technique: soft tissue mobilization / kneading / rolling / pressing / percussion / traction / passive stretching] to [region] at [light / moderate / deep] intensity
  • (Add technique-to-region mappings as performed; note patient-guided adjustments.)
• Acupressure points: (Include if discrete component of treatment.)
  • [Point code with laterality] — [sustained pressure / kneading], [hold time or repetitions], [clinical intent]
  • [Ashi point at specific location] — [technique parameters], [clinical intent]
  (Use standard alphanumeric nomenclature; document tender points as ashi with anatomical location.)
• Duration: [Total treatment time in minutes]. (If billing timed codes: [Total timed minutes], [Start time]–[Stop time]. Count only skilled treatment time.)

Response and Tolerance

Tolerance: [well / fair / poor]. [Modifications made: reduced pressure, avoided region, repositioned]. Immediate response: [Pain rating pre→post], [functional changes: ROM, reduced guarding], [patient-reported benefit].

Adverse events: [No adverse events / Description of event(s), severity, and management provided]. (Required — always document presence or absence.)

Assessment

[Brief clinical impression connecting findings to intervention and outcome]. [Framework: biomedical and/or traditional as appropriate to practice]. [Clinical trajectory: progressing / stable / requires plan modification]. (Avoid diagnoses or pattern identifications not supported by evaluation.)

Plan

Home program: [Self-care instructions: self-acupressure points, stretches, heat/ice; frequency and duration; safety cautions]. [Patient verbalized understanding / handout provided]. (Omit if no home program given.)

Follow-up: [Proposed visit frequency]. Next session focus: [Region, technique, or point strategy]. (If applicable: Referral/escalation plan: [Indications for referral if red flags emerge or inadequate response].)

Signature: [Practitioner name], [Credentials]