Your clinic’s Information:



(SOAP) (Initial Consultation Format)

Patient’s Info: Name, bday, id.

Date of Service:

Subjective:

-Record down what the patient tells you, his/her symptoms, problems, issues.

- What happened? Injury? Car accident? Chronic or acute symptoms?

- How long has it been since pain symptoms first occurred?

- Patient’s history (chronological order)

- Frequency (how often is pain? Sometimes? Constant?

- Intensity (how severe is the symptom? Use scale 0-10 )

- Duration (how long does pain symptom last?)

- Received any tx before from other docs?

- How do these symptoms affect patient’s daily life?

- What activities are hindered?

- Any medications? X-rays, MRIs findings?

Objective:

- Record your (the acupuncturist’s) findings here, this should include Eastern objectives such as Tongue, Pulse, Color, etc.. as well as Western objectives such as ROM (range of motion). Check pt’s flexion, extension and rotation of the c-spine and L-spine (if patient’s symptoms relate to these areas).

o Ex: ROM of c-spine: Flexion is limited with pain in C4-C5 and C5-C6. Extension was restricted with very little degrees of freedom. Left and right turns were within normal limits with slight pain in right Scapualr.

- Check for muscle tenderness, stiffness etc. and record specific muscle or organ names.

- May use traditional Chinese medicine’s principles (the Qi) and acupressure points to describe findings. Ex: excess of qi in the Tai Ping Xue Wei.

Assessment:

- According to patient’s complaint, your objective findings, patient’s history and overall health, how much likely is the patient going to recover? What do you expect for this patient?

- If patient have disc problems, recovery may be slow.

Plan:

- What kind of treatment are you implementing on the patient?

- How frequent? Ex: 2x a week for a session of 12 visits.

- Acupuncture (for what?), massage (for what?) manual therapy (for what?)

(SOAP) (Follow -ups Format, daily progressive notes)

Patient’s Info: name, bday, id.

Date of Service:

Subjective:

- is patient feeling better? Where? What?

- What has improved, or gotten worse or stayed the same?

- Reduction in frequency, duration and or intensity of pain?

- Improve daily activities?

Objective:

- better ranges of motion (ROM)?

- More flexibility? Less muscle tension or rigidity?

- Better Qi flow or energy? Pulse? Tongue? BP? Color?

Assessment

- is patient’s recovery on par with expectations? Exceeding expected or outcome not so well? If not improving, changing treatment plan?

Plan /treatment: (THE MOST IMPORANT PART !!!)

- What you actually did for the patient today, MUST BE DOCUMENTED specifically.

- Acupuncture codes are billed in units of roughly 15 minutes for insertion or re-insertion of the needles. MUST indicate Where, Why, and When.

- Ex:

Initial 15 minutes of Acupuncture: insertion of needle into (x point or region), to assist in the flow of Qi to reduce muscle pain.

2nd 10 minutes: reinsert in (point x) to further reduce muscle spasm and regulate Qi, open up blockages along lung meridian.

3rd 9 minutes: Flips patient to his back and insert in (x point) to reduce muscle tension, plus infrared heat, to relax patient’s Gluteus maximus muscles

4th 13 minutes: Guasha on upper thoracic to release toxins and relieve muscle tightness.

• This would be billed as 3 units of acupuncture, and 1 unit of Guasha/manuals.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download