TCM Insights
Follow-Up Visit Documentation for TCM and Acupuncture
Follow-up visits should not be copy-pasted initial intakes. A tight interval history plus trend in objective findings shows medical necessity and guides the next point prescription.
Table of Contents
Interval History in Two Minutes
Open Subjective with response since last visit: better, worse, or mixed; which symptoms moved first. Reference prior Plan (“patient reports completing acupressure ST36 daily 5/7 days”).
Outcome Measures That Matter
Use consistent scales (NRS pain, PSQI sleep, weekly migraine days). Record in Subjective and mirror key numbers in Assessment: “Pain NRS 7→4 over 3 visits.”
When to Adjust Points, Frequency, or Refer
Document clinical reasoning when changing protocol: “Reduced visit frequency to biweekly as acute inflammation resolved; added motor points for residual weakness.” Referral discussions belong in Plan with patient agreement noted.
Documenting Maintenance Care
When shifting to maintenance, state functional goal (“prevent flare of low back pain during golf season”) and objective criteria for spacing visits.
Follow-Up SOAP Templates
EMR follow-up templates pre-load headings for interval history and outcome table—saving time while preserving SEO-rich, patient-specific content in your clinic blog and portal if you publish education separately.
Streamline your acupuncture documentation
Aura Cure EMR helps TCM clinics draft structured SOAP notes, track tongue and pulse trends, and share clear treatment plans—with HIPAA/PIPEDA/GDPR-oriented privacy controls.
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