Inpatient/Acute Care Acupuncture Consult Note

Note Type: Inpatient/Acute Care Acupuncture Consult Note

Date/Time of Encounter: [Date and time of bedside encounter]

Author/Credentials: [Name, degree(s), licensure]

Location (Hospital/Unit/Bed): [Hospital name / unit / bed]

Consult Requested By: [Requesting service and clinician name/title]

Reason for Consult

[Consult question as stated by requesting team] (Document exactly as framed without inference. If not specified in the order, document how clarification was obtained and from whom.)

• Symptom targets: [pain / nausea / anxiety / dyspnea / constipation-ileus / insomnia / other: specify]
• Urgency/timing constraints: [Time-sensitive windows, peri-procedural timing, or coordination constraints]

Clinical Context

[Primary diagnosis] [Hospital day / post-operative day and procedure with date if relevant] [ICU vs floor status] [Key milestones relevant to acupuncture decision-making] [Current symptom burden summary] (Limit to 3–5 sentences. Include only details affecting acupuncture timing, risk, or benefit.)

Safety Screen

(Required section. Do not infer or assume. If information is unavailable, explicitly state what could not be verified and how this affected the treatment decision.)

• Anticoagulation/Antiplatelet: [Medication name(s), dose, route, schedule, last administered date/time] (Include VTE prophylaxis vs therapeutic dosing and other bleeding risk modifiers.)
• Coagulation/Labs: [Platelet count with date/time] [INR with date/time] [Other relevant labs] (Include only if clinically relevant to bleeding risk.)
• Lines/Drains/Devices: [Central line / PICC / arterial line / chest tube / wound vac / epidural / ostomy / pacemaker-ICD / other] [Location(s)] [Resulting no-needle zones]
• Recent procedures/surgical sites: [Location(s)] [Restrictions and no-needle zones]
• Isolation status: [Type of precautions and workflow modifications]
• Skin integrity at intended sites: [Intact / bruising / rash / wounds / edema] [Action taken]
• Mobility/cognitive/behavioral safety: [Delirium status / fall risk / agitation / communication ability] [Implications for safe treatment]
• Technique modifications based on risk: [Superficial needling only / avoid electrical stimulation / reduced retention time / alternative positioning / prolonged pressure post-removal / acupressure-only / defer treatment] (Specify rationale.)
• Unavailable safety information: [Data not verified and how this altered the plan] (Omit if all safety data was verified.)

Subjective

[Focused symptom history for each target: onset, location, severity, quality, aggravating/relieving factors, what has or has not helped this admission, functional impact on sleep/mobility/oral intake/therapy participation] [Patient-stated goals for this session] (A brief direct quote may be included if it clarifies distress or goals.)

• Pertinent ROS: [Bleeding tendency, prior needling reactions, dizziness/syncope history, pregnancy status if applicable]
• Relevant PMH/PSH: [Past medical or surgical history directly affecting today's treatment]
• Current symptom medications: [Analgesics/antiemetics/anxiolytics and effectiveness today]

(If information is unavailable due to patient somnolence, delirium, or language barriers, document why and any collateral sources used.)

Objective

• Vitals: [Vitals influencing safety] (Include only if pertinent: hypotension, fever, tachyarrhythmia, oxygen requirement.)
• Targeted exam: [Findings relevant to symptom targets: pain location/tenderness, ROM, abdominal exam for GI targets, skin at intended needle sites]

Traditional East Asian Medicine Assessment

[Tongue, pulse, palpation findings] [Plain-language interpretation and how findings informed point selection] (Include only if performed and used for decision-making. Omit this subsection entirely if not performed.)

Assessment

[Clinical impression linking symptom targets to acupuncture decision] [Suitability for acupuncture today: indications, expected benefit, contraindications checked, risk mitigation summary] (If treatment is deferred, state the explicit reason and any alternative non-needle interventions offered within scope. Do not diagnose new medical conditions outside scope; note concerns and that the primary team was notified.)

Treatment Provided

(If no procedure performed, replace this section with a one-sentence statement of why treatment was deferred.)

• Pre-procedure verification: [Patient identity verified / time-out per policy / positioning and privacy ensured / safety checks confirmed]
• Consent: [Capacity: intact / impaired with surrogate] [Risks/benefits/alternatives reviewed, questions answered] [Consent obtained: verbal / written] [Interpreter used: yes / no]
• Modality: [Body acupuncture / auricular / scalp / acupressure-only / electroacupuncture]
• Needle details: [Single-use sterile needles] [Size/gauge if relevant] [Adjuncts: ear seeds / heat lamp / other]
• Points and technique: [Point names with laterality] [Depth and stimulation method: manual / electrical]
• Electroacupuncture parameters: [Frequency (Hz)] [Intensity] [Waveform] [Duration] (Include only if electroacupuncture used.)
• Total needles: [Number inserted] Retention time: [Minutes]
• Needle count reconciliation: [Needles in] / [Needles out] (Confirmed all removed and disposed per protocol.)
• Patient response: [Immediate symptom change with before/after scores if available] [Tolerance and comfort] [Functional changes observed]
• Adverse events: [None / bleeding controlled with pressure / vasovagal symptoms and response / other] (Document actions taken and outcome.)

Recommendations and Plan

• Inpatient acupuncture plan: [Recommended frequency] [Criteria to continue: documented benefit, patient preference] [Criteria to pause/stop: no benefit after specified sessions, worsening coagulopathy, new lines near planned sites, hemodynamic instability]
• Self-care/non-needle adjuncts: [Acupressure points with instructions] [Breathwork or relaxation guidance] [Positioning/heat/cold recommendations]
• Care coordination requests: [Timing around PT/OT or procedures] [Pre-medication considerations] [Nursing assistance or interpreter needs]
• Transition planning: [Outpatient acupuncture referral or resources] [Criteria for continuation] (Include only if relevant to this admission.)

Communication and Follow-Up

• Primary team communication: [Mode: secure chat / phone / in-person] [Recipient name/role] [Timestamp] [Key recommendations conveyed] [Escalation guidance provided]
• Post-treatment monitoring: [What nursing should observe and duration] [Red flags: persistent bleeding, syncope/fall, new chest pain or dyspnea after thoracic needling, signs of infection at needle sites]
• Next visit: [Planned date/time or criteria for follow-up] (If treatment was deferred, specify conditions for proceeding.)