Moxibustion Procedure Note

Date of Service: [date]

Start Time: [time] End Time: [time]

Location: [clinic/room]

Clinician: [name, credentials]

Procedure Overview

[Brief summary of moxibustion performed] (State whether moxibustion was [stand-alone / adjunct to acupuncture]. Specify technique category [direct / indirect], delivery method [stick/pole / moxa box / cone with barrier / cone without barrier / needle-top / warming needle], and moxa product type [mugwort stick / loose moxa / smokeless/charcoal / other]. Identify primary anatomical regions treated and document total treatment duration in minutes. Do not infer from prior notes; document explicitly for this encounter.)

Indication

[Clinical rationale] (Briefly state primary symptom or complaint addressed, working diagnosis and/or TCM pattern if applicable, treatment intent [symptom relief / functional improvement / supportive care], and baseline severity if measured [e.g., pain score, ROM limitation]. If indication is documented in an associated encounter note, reference that note and state moxibustion was performed per treatment plan.)

Pre-Procedure Assessment

Safety Screening (Document as brief statements indicating presence, absence, or not assessed. Do not default to "denies" if not assessed.)

• Heat/burn risk factors: [reduced sensation / neuropathy / diabetes with sensory loss / inability to report heat or pain / none / not assessed] [details if present]
• Skin integrity at treatment sites: [intact / compromised / open wound or lesion present / not assessed] [location and details if applicable]
• Smoke sensitivity: [asthma / reactive airway / prior intolerance / none / not assessed]
• Allergies: [mugwort / adhesives / topical agents / none / not assessed]
• Pregnancy status: [pregnant / not pregnant / not applicable / not assessed] (If relevant to site selection.)

Informed Consent

• Consent obtained: [verbal / written]
• Discussion included: nature and purpose of moxibustion; material risks (burns, blistering, skin hyperpigmentation, smoke irritation, allergic reaction, infection risk); alternatives; patient questions answered; patient agreed to proceed.
• (If direct or scarring moxibustion: document explicit discussion of intent to blister or scar and confirm written consent obtained per organizational policy.)

Procedure Details

Patient Position: [supine / prone / seated / side-lying]; treatment areas appropriately exposed and draped.

Sites Treated (One row per site. Do not infer from prior notes; document explicitly for this encounter.)

Site/Point	Anatomic Description	Laterality	Technique	Dose
[acupuncture point name]	[anatomic description]	[left / right / midline]	[stick/pole / moxa box / cone with barrier / cone without barrier / needle-top / warming needle], [direct / indirect]	[minutes or number of applications]

Technique Narrative

[Description of heat delivery and safety measures] (In 2–4 sentences, describe: hovering or moving technique and approximate distance maintained; barrier used if applicable; ash and ember control; patient shielding; whether clinician remained continuously present. Note any adjustments made for comfort or safety.)

Monitoring

• Skin monitored [throughout / intermittent checks] for excessive erythema or pain.
• Patient instructed to report excessive heat immediately.
• Adjustments made: [increased distance / shortened exposure / stopped early at site / none]
• Ventilation and smoke mitigation: [window or open door / exhaust fan / air purifier / smokeless moxa used / other]
• Fire safety: [water or extinguisher available / ash-safe container / per facility protocol]
• (If clinician did not remain continuously present: document reason and monitoring method used.)

(If warming needle or needle-top moxa with needle insertion: document time-out performed verifying patient identity, procedure, and sites with laterality; document sharps disposed in approved container.)

Response and Post-Procedure Assessment

Tolerance

• Overall: [well tolerated / limited by heat sensitivity / limited by smoke irritation / other]
• Patient-reported response: [brief description or short quote]
• Objective observations: [expected mild erythema / excessive reaction / cough or wheeze / vasovagal symptoms / none]

Post-Procedure Skin Check (Document for each treated region.)

• [Region or site]: [expected mild erythema / normal / abnormality with description]
• (If burn, blister, or lesion: document location, measured size, severity description, immediate management, and follow-up or referral plan.)

Complications: [None / burn / blister / allergic reaction / smoke intolerance / other with management] (State "None" only if post-procedure skin check was performed and documented above.)

Aftercare Instructions

Patient received instructions including:

• Expected findings: mild redness and warmth that resolve
• Warning signs requiring attention: blistering, increasing pain, spreading redness, drainage, fever, persistent cough
• Skin care: keep area clean and dry; avoid irritants
• First aid for delayed burns: cool running water, no ice, contact clinic
• When to seek urgent care: [per clinic protocol]
• Written materials provided: [yes with title / no]

Plan

• Follow-up: [timeframe] (May reference encounter note if plan documented there.)
• Modifications for next session: [shorter duration / smokeless moxa / fewer sites / alternative modality / none]
• Provider coordination: [details / none]

Clinician Signature: [electronic signature, credentials]