Traditional Chinese Medicine Consultation Note (Integrative Care)

Patient: [Patient full name]
DOB: [Date of birth]
Date and Time of Consultation: [Date and time]
Setting: [clinic / telehealth]
Author: [Author name and credentials]
Referring Clinician: [Referring clinician name, role, contact information]
Interpreter: [Language and modality] (Include only if interpreter used)

Consult Synopsis

(Produce a compact block of 6–10 lines. Include only content explicitly known from the encounter; omit any line that cannot be supported by available data.)

Reason for consult: [One-line reason]
Biomedical working diagnoses: [Key diagnoses]
Primary TCM pattern: [Primary pattern diagnosis]
Secondary TCM patterns: [Secondary or contributing patterns] (Omit if none)
High-risk flags/precautions: [Key risks and contraindications]
Recommended modality mix: [Modalities] — [Initial frequency and duration]
Reassessment: [Timing and criteria]
Requests to referring clinician: [Specific asks or information needed]

Reason for Consultation

• [Referring clinician's specific questions or goals]
• [Clarification of scope if referral was vague] (Include only if scope was clarified)
• [Discordance between referral question and patient understanding] (Include only if discordance noted)

Data Sources Reviewed

• [Patient interview] (Note reliability if limited)
• [Records reviewed: referral note, imaging, labs, specialty notes]
• [Collateral historian and relationship] (Include only if used)
• [Key data unavailable and requested] (State that recommendations are provisional pending receipt)

Subjective

Chief Concern

"[Patient's own words]"

History of Present Illness

[Narrative: onset, course, location, severity, quality, timing, exacerbating and relieving factors, functional impact, associated symptoms, relevant negatives, prior workup and treatments with responses, patient goals and preferences] (Include explicit consideration of neurologic or systemic red flags and their disposition.)

TCM-relevant symptom domains: [Sleep quality]; [Energy and fatigue pattern]; [Stress and mood]; [Digestion, appetite, bowels]; [Thermoregulation and sweating]; [Menstrual history] (Include only domains informing safety or pattern differentiation)

Medical and Surgical History

• [Bleeding disorders and anticoagulation status]
• [Implantable devices: pacemaker, ICD, other electronics]
• [Immune compromise or infection risk factors]
• [Pulmonary history] (Include if thoracic needling considered)
• [Neurologic history including seizure or syncope]
• [Skin or connective tissue conditions affecting integrity]
• [Pregnancy or lactation status] (Include if applicable)
• [Relevant behavioral health history]
• [Major surgeries pertinent to referral or procedural safety]

Medications, Supplements, and Allergies

(This section requires high reliability; never leave blank. If incomplete, explicitly state what is unknown and how it will be obtained.)

• Prescription medications: [Names with doses and frequencies]
• OTC medications: [Names with doses and frequencies]
• Supplements and herbs: [Product name, brand or source if known, dose and frequency]
• Allergies: [Agent — reaction type and severity]
• Unknowns: [Specific gaps and plan to reconcile] (Include if medication list incomplete)

Social History

• [Functional goals and work or role demands]
• [Tobacco, alcohol, cannabis, or substance use relevant to procedures or herb interactions]
• [Diet patterns relevant to TCM counseling]

Objective

Vitals and General Appearance

• [Vital signs] (Note if patient-reported; include only if obtained)
• [General appearance: level of distress, body habitus, affect]

Focused Physical Examination

(Tailor to referral concern. Document pertinent positives and negatives. Do not use normal exam macros unless actually performed.)

• [Inspection and observation relevant to complaint]
• [Gait and function]
• [Range of motion: active and passive]
• [Provocative maneuvers and results]
• [Neurologic screen: strength, sensation, reflexes, special tests]
• [Palpation and tenderness mapping]

TCM Examination

• Tongue: [Body color]; [Shape]; [Coating]; [Moisture]; [Notable features] (State "not assessed" and reason if not performed)
• Pulse: [Rate]; [Depth]; [Strength]; [Qualities and positions] (State "not assessed" and reason if not performed)
• Palpation: [Channel tenderness and ashi points]; [Abdominal findings] (Include abdominal only if performed)
• Observation: [Complexion]; [Shen and affect]; [Voice, breath, odor] (Include only elements assessed)

Diagnostics Reviewed

• [Imaging summary and clinical relevance]
• [Laboratory findings: inflammation, metabolic, hepatic, renal function]
• [Other diagnostics with interpretation]

Assessment

(Organize by problem in order of clinical importance. Do not upgrade diagnoses beyond available data; document uncertainty and next steps when serious conditions are suspected.)

[Problem 1]

Biomedical impression: [Working diagnosis, severity, chronicity, functional impact, red flags considered and disposition, relationship to referral question]

TCM pattern differentiation: [Primary pattern]; [Secondary patterns] — [Eight Principles: interior/exterior, hot/cold, excess/deficiency, yin/yang]; [Zang-fu and channel involvement]; [Key supporting evidence] (Label as provisional if data incomplete; note what would refine the pattern)

[Problem 2]

Biomedical impression: [As above]

TCM pattern differentiation: [As above]

(Repeat problem blocks as needed)

Risk and Precautions Synthesis

• Acupuncture: [Bleeding and bruising risk]; [Infection risk]; [Syncope history]; [Anatomic risk zones]; [Anticoagulant status]; [Immune status]
• Electroacupuncture: [Implantable devices]; [Seizure history]; [Current through thorax precautions]
• Moxibustion and heat therapies: [Burn risk]; [Neuropathy or impaired sensation]; [Respiratory sensitivity]
• Cupping and gua sha: [Anticoagulation]; [Skin fragility]; [Bruising expectations discussed]
• Herbs and supplements: [Pregnancy or lactation]; [Hepatic and renal function]; [Polypharmacy risk]; [Product quality]; [Allergies]
• Stop and seek care warnings: [Signs and symptoms prompting urgent evaluation]

Plan

Goals and Outcomes

• [Patient-centered functional goals]
• [Symptom scales or objective measures to track with baseline if available]

Recommended Modalities

• [Modality 1]: [Biomedical rationale]; [TCM rationale]; [Dose and frequency]; [Trial length]; [Reassessment timing]; [Provided here / external referral]
• [Modality 2]: [As above]

Home Program

• [Acupressure points with locations and frequency]
• [Stretching, mobility, qigong, or breathwork]
• [Sleep hygiene strategies]
• [Dietary guidance aligned with TCM]

Treatment Details

(Include only if a procedure was performed today)

• [Informed consent verified]; [Time-out if applicable]
• [Patient position and regions treated]
• [Needle type and size]; [Technique]; [Points or regions per clinic policy]; [Manual / electrical stimulation with settings]
• [Retention time]; [Patient tolerance and response]
• [Adverse events: none / description]
• [Post-treatment instructions given]

Herbal Medicine Plan

(Include only if recommending herbal medicine)

• [Formula or patent name]; [Key components or manufacturer]
• [Dose, route, frequency, duration]
• [Intended indication and target symptoms]
• [Safety screening: interactions, pregnancy, hepatic and renal, allergies]
• [Quality and sourcing]
• [Monitoring plan and stop rules]
• [Communication plan with PCP or pharmacist]

Coordination Plan

• My actions: [What I will do and when]
• Referring clinician: [Requested diagnostics, clearances, medication adjustments, referrals]
• Patient: [Tasks before next visit]

Communication to Referring Provider

Re: [Patient name] — [Restated referral question]
Impression: [Prioritized biomedical diagnoses]; [Key TCM patterns]
Safety considerations: [Top patient-specific risks and precautions]

• Recommendations: [Clear next steps with time frames]
• Co-management: [Who orders and monitors what]
• Follow-up: [Timing and triggers for earlier contact]

Data Gaps and Limitations

(Include only if applicable)

• [Data not yet available and requested]
• [Exam components not performed and why]
• [Uncertainty statements: what would change assessment or plan]

Patient Education and Consent

• [Counseling provided: modalities discussed with risks, benefits, alternatives, realistic expectations]
• [Patient questions addressed and understanding affirmed]
• [Informed consent obtained for procedure] (Include only if procedure performed)
• [Post-procedure instructions documented] (Include only if procedure performed)
• [Advised not to delay indicated conventional evaluation] (Include when relevant)