Traditional Chinese Medicine Re-evaluation/Progress Report (Episode of Care)

Traditional Chinese Medicine Re-evaluation / Progress Report

Report Date: [Date]

Patient Name: [Full name]

DOB: [DOB]

Provider: [Name, credentials]

Episode Start Date: [Date]

Visits Covered: #[Start visit number] to #[End visit number] (Date range: [Start date] to [End date])

Primary Complaint(s): [Primary complaint(s)]

Reason for Re-evaluation

• [Trigger or rationale for this report] (Include 1–3 short bullets such as scheduled periodic re-evaluation, symptom or functional change, plateau or flare, new complaint, revised pattern differentiation, or care coordination decision point.)

Interval History

[Patient-reported trajectory since last progress report] (Brief narrative integrating: chief complaint status with specifics on improvement, worsening, or stability; symptom quantification including pain levels, frequency, functional tolerance; functional outcomes such as activities regained, work capacity, ADL changes; treatment response characteristics including sustained vs short-lived effects; adherence to home program or herbal prescriptions; interval health changes including new diagnoses, injuries, or medication changes. Include direct patient quotes for pivotal statements. If patient cannot self-report, state the information source and limitations.)

Objective Findings

Outcome Measures:

• [Pain metric]: [Baseline] → [Last report] → [Current]
• [Functional/disability metric]: [Baseline] → [Last report] → [Current]
• [Additional metric if applicable]: [Baseline] → [Last report] → [Current] (Include only if relevant.)

TCM Assessment:

• Tongue: [Body color, shape, coat, moisture, notable changes since last report] (If not assessed, state reason.)
• Pulse: [Positions assessed, key qualities, rate/rhythm as relevant] (If not assessed, state reason.)
• Palpation: [Channel findings, ashi points, temperature differences as applicable]

Exam/Vitals: [Pertinent conventional findings] (Include only when clinically relevant such as ROM changes, neurological screen, or vitals. Omit this line entirely if none are pertinent.)

Assessment

(Organize by active problem, highest severity first. Replicate the block below for each problem addressed this interval.)

[Problem]: [Diagnosis or complaint label]

• Status and trajectory: [Improving / Plateau / Worsening] — [acute flare vs chronic trend with supporting subjective and objective evidence]
• Goal progress:
  • [Goal] — [Met / Partially Met / Not Met / Modified] — [Brief justification]
• Updated pattern differentiation: [Current primary pattern(s) in English, pinyin optional] (Note changes since last report with tongue, pulse, symptom, and functional evidence. If pattern cannot be confirmed due to missing data, state "pattern differentiation deferred" and reason.)
• Contributing factors or barriers: [Adherence, psychosocial factors, ergonomics, comorbidities]
• Interval treatment summary: [Modalities used, treatment principles, significant strategy changes]
• Safety concerns: [Red flags, new neurological deficits, or safety issues with actions taken] (Include only if present this interval.)

Plan

• Continuation decision: [Continue / Modify / Taper / Discharge / Hold pending workup]
• Frequency and duration: [Visit cadence and trial length, e.g., 1x/week for 4 weeks then reassess]
• Treatment approach: [Planned treatment principles, modality focus, herbal formula adjustments and monitoring as applicable]
• Updated goals:
  • [Functional, measurable goal] — [Target timeframe]
• Home program: [Key self-care elements and frequency]
• Reassessment plan: [When outcome measures will repeat; criteria prompting plan modification such as lack of improvement after defined trial, worsening symptoms, or adverse reactions]
• Care coordination: [Referrals, records sent/requested, interprofessional communication] (Include only if applicable this interval.)
• Adverse events: [Events reported with severity, management, follow-up] (If explicitly asked and denied, may note "Patient denies adverse events since last report." Omit if not addressed.)