Cupping/Gua Sha Therapy Procedure Note

Date/Time: [Start time] – [End time] ([Total duration])

Location: [Facility and room/location]

Treating Clinician: [Name, credentials]

Patient Identifiers: [Per facility policy]

Procedures Performed

• Cupping therapy: [dry / wet]; [static / moving]; suction method: [pump / fire / mechanical]
• Gua sha therapy: tool type: [tool description/material]; stroking style: [unidirectional / multidirectional / press-stroking]

(Include only the modalities actually performed. If a modality was planned but not performed, note the modality and reason. Do not include placeholder bullets for modalities not performed.)

Indication

[Clinical rationale: condition/symptoms addressed, relevant location and functional impact, reason for selecting modality]

(1–3 sentences. Omit this section only if this is a narrow addendum to a separately documented encounter.)

Contraindications and Precautions Screened

• Bleeding risk: [Pertinent positives/negatives regarding anticoagulants, bleeding disorders, easy bruising, recent procedures]
• Skin integrity at treatment sites: [intact / lesions / rash / infection / recent procedure / fragile skin] [location details if abnormal]
• Sensation at treatment sites: [intact / diminished / altered]
• Other relevant precautions: [e.g., lymphedema risk, implants, pregnancy-related considerations]

(Document "not assessed" for any element that was not evaluated rather than omitting.)

Informed Consent

Consent obtained: [verbal / written]. Discussed: what will be done and where; expected skin changes (erythema, petechiae, ecchymosis); material risks (blistering, burns, skin breakdown, infection if skin breaks, vasovagal symptoms, symptom flare); alternatives including no treatment; questions answered; patient agreed to proceed. Patient counseled that visible marks can resemble bruising and may be misinterpreted by others, and advised to disclose recent cupping or gua sha therapy if evaluated elsewhere for skin findings.

Pre-Procedure Assessment

(Include if baseline measures were obtained; omit section if none.)

• Pain: [Score/scale] at [location]
• Function/ROM: [Measure and region]
• Skin exam at planned sites: [intact / pre-existing lesions or discoloration with locations]
• Vitals: [Values]

(Include vitals only if clinically indicated.)

Preparation

• Hand hygiene: performed
• Skin preparation: [cleaned / antiseptic prep with agent for wet cupping]
• Lubricant: [type/product]
• Equipment: [cup sizes/number and material; gua sha tool type/material] — [single-use/disposable / reprocessed per protocol]
• Patient positioning: [position and supports]

(Include lubricant only if used for moving cupping or gua sha.)

Procedure Details

(Include only the subsection(s) for modalities actually performed.)

Cupping Therapy

• Technique: [dry / wet]; [static / moving/gliding]
• Suction method and intensity: [pump / fire / mechanical]; [light / moderate / strong]
• Cups: [number] cups; sizes [sizes or range]; [glass / silicone / plastic]
• Locations treated: [anatomic regions with laterality]
• Dwell time: [time per application] and/or [total cupping time]
• Moving cupping parameters: [movement pattern/path, number of passes, pace]
• Patient tolerance: [tolerance description; any modifications made]

(Include moving cupping parameters only if moving/gliding technique was used.)

Wet Cupping Specifics

(Include only if wet cupping was performed.)

• Sterile technique: maintained; sterile gloves; sterile field
• Skin lancing: [method/device]; [number] incisions at [locations]
• Hemostasis: achieved [method]
• Dressing: [type] applied to [location]

Gua Sha Therapy

• Tool and material: [tool type/material]
• Lubricant: [type/product]
• Technique: [unidirectional / multidirectional / press-stroking]; pressure [light / moderate / firm]
• Duration: [total time]; [time per region]
• Treatment endpoint: [mild petechiae / patient tolerance / other endpoint]
• Regions treated: [anatomic regions with laterality]
• Patient tolerance: [tolerance description; any modifications made]

Skin Response

• Expected therapeutic skin changes reviewed with patient: [erythema / petechiae / ecchymosis]
• Immediate post-procedure findings:
  • [Region/laterality]: [erythema pattern], [petechiae/ecchymosis distribution], [edema/tenderness], skin [intact / not intact]
• Unexpected findings: [none / blistering / burns / wheals / skin breaks / unusual pain]

(Add additional location bullets as needed for each treated region.)

Patient Tolerance and Response

• Tolerance: [tolerated well / procedure paused / procedure terminated]; [supporting details: no dizziness, acceptable discomfort level, etc.]
• Patient-reported response: [pain score change; symptom change or perceived benefit; or neutral response]
• Objective changes: [ROM/functional measure changes]

(Include objective changes only if measured.)

Complications

Complications: [none observed]

(If complications occurred, document: event description, severity, skin integrity impact, immediate management, and safety instructions provided.)

Aftercare Instructions

• Expected course: [duration of marks and tenderness discussed]
• Skin care: keep clean; avoid friction/irritants; [dressing removal timing if applicable]
• Activity guidance: [activities to avoid/modify and duration]
• Return precautions: increasing pain, spreading redness/warmth, drainage, fever, blistering, numbness, systemic symptoms
• Communication: advised to mention recent cupping/gua sha to other clinicians if evaluated for skin findings
• Written instructions: [provided / not provided]

(Include activity guidance only if restrictions apply.)

Disposition and Follow-Up

• Condition on leaving: [stable, ambulatory / other]; [observation period if vasovagal symptoms occurred]
• Follow-up plan: [next session timing / reassessment date / as needed]
• Modification criteria: [criteria for adjusting intensity, spacing, or discontinuing therapy]

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