Your Path to Wellness: Acupuncture Treatment Record

Please remove this mandatory questions recommendation before publishing.

Mandatory Questions & Core Rationale:

1. Client Identity & Date

• Questions: Full Name, Date of Birth, Date of Visit (for each session).
• Why: These are absolute fundamentals for accurate record-keeping. They uniquely identify the client, prevent confusion between individuals with similar names, and anchor every piece of information in the record to the correct person and time. The date creates the chronological treatment timeline essential for tracking progress.

2. Informed Consent Acknowledgement

• Question/Section: The client's signature and date confirming they understand the nature, potential benefits, and common sensations of acupuncture treatment, and agree to proceed.
• Why: This is a cornerstone of ethical and professional practice. It represents a clear agreement between practitioner and client, affirming that the client has been informed and is participating voluntarily. It establishes mutual understanding and respect, forming the basis of the therapeutic relationship.

3. Presenting Complaint & Goals

• Questions: Primary Reason for Seeking Treatment, Treatment Goals.
• Why: This defines the entire purpose of care. It focuses the clinical assessment and ensures the treatment plan is targeted and relevant to the client's own expressed needs. It provides the benchmark against which all progress is measured.

4. Medical & Safety Screening

• Questions: Current Medications, Allergies, Pregnancy Status (if applicable), Bleeding Disorders or use of Anticoagulants, History of Seizures/Fainting.
• Why: This is critical for client safety. This information directly influences point selection, needling technique, and treatment approach to avoid adverse reactions. For example, knowing about a medication that thins the blood requires gentler needling; an allergy to metals necessitates special needles; pregnancy contraindicates certain acupuncture points.

5. Treatment Details for Each Session

• Questions: Points Used (with laterality), Needle Retention Time, and Practitioner Observations/Client Response.
• Why: This documents the specific action taken. Recording points is necessary to build an effective and non-repetitive treatment strategy. Noting the client's response (e.g., "reported feeling relaxed," "experienced De Qi at LI-4") provides immediate feedback on the treatment's effect and guides future sessions. It creates a reproducible record of what was done.

6. Treatment Plan & Progress Notes

• Questions: Initial assessment-based Treatment Plan (including frequency), and periodic Progress Summaries.
• Why: This demonstrates structured, professional care. The initial plan shows forethought and a rationale for the course of treatment, moving beyond a single session. Regular progress summaries force clinical reflection, allow for plan modification based on outcomes, and demonstrate whether the treatment is effective or needs adjustment.

7. Practitioner Identification

• Question: Practitioner's Name (and ideally, signature for each session).
• Why: This establishes accountability and clarity. It confirms who provided the care and who is responsible for the information in the record. This is essential for continuity if another practitioner in the same clinic needs to review the file.

Rationale Summary:

These mandatory elements collectively ensure that the record fulfills its primary purposes: to identify the client uniquely, to document consent and ensure ethical practice, to promote safety by screening for risks, to record the specific care provided, to guide a logical treatment strategy with clear goals, and to track outcomes over time. A record with these components supports high-quality, client-centered, and responsible clinical practice.