ACC Follow-up clinical note requirement
| Requirement | Example | |
| Subjective | ||
| Results/Progress | The patient reports that (Don’t write: The patient feels better) 1. Evaluation of the patient’s response to previous treatments. (Progress or changes in symptoms, pain levels, or functional abilities) Better?No change(Much the same)? Worse? 2. Where is the pain(location)? 3. Is it measurable? 4. How was it caused? 5. How was the condition getting improved? 6. Document the patient’s response to treatment, any changes in symptoms, and any adverse reactions experienced. | Patterns of pain: 1. much the same/The pain is slightly reduced/The pain feels worse than the last visit. 2. The pain is worse when sleeping at night on the right/left side 3. The pain is worse when sitting for a prolonged period of time 4. The pain is better with movement pain type: Intermittent, Constant, Throbbing, Sharp, Dull, Stabbing, Ache, Pain, Burning, Pins and Needles Sensation Must include: Numerical Pain Rating Scale (NPRS): Most of the time 5/10, 7/10 at worst Patient-Specific Functional Scale (PSFS): To be able to lift 5kg heavy object 6/10 To be able to sleep on the affected side 6/10 To be able to turn around the neck 6/10 Less pain(measure)on wb. decreased swelling(measure). increased dorsiflexion (measure). Tolerated well does not describe how effective a treatment is. Physio: Feels as though there has been an improvement in her pain whilst walking. able to walk around 15mins prior to the onset of some pain.Not as swollen and not as stiff in the morning. |
| Objective | ||
| examination | Physio:Knee to wall L=2cm,R=4cm. Swelling measured around malleoli L=20cm,R=22cm. Single leg balance eyes open L 40secs,R 20secs. Hop L full and pain free, R=full with pain on landing 4/10 | |
| Observation | Observation of a lower back sprain may involve assessing various aspects of the individual’s condition. Here are some observations that can be made: Posture: Observe the person’s posture while standing, sitting, or walking. Look for any signs of asymmetry, favoring one side, or stiffness in the lower back area. Movement limitations: Note if the person experiences difficulty or pain when bending forward, twisting, or performing specific movements that involve the lower back. They may exhibit guarded movements or avoid certain actions altogether. Facial expressions: Pay attention to their facial expressions, looking for signs of pain, discomfort, or grimacing when they move or perform specific activities that engage the lower back. Mobility: Assess their mobility and range of motion in the lower back area. Observe if they have restricted movement or if their range of motion is limited compared to normal. Muscle tension or spasm: Look for any visible signs of muscle tension or spasms in the lower back area. This may present as visible muscle contractions or palpable areas of tightness. Gait: Observe their walking pattern or gait. A person with a lower back sprain may exhibit altered gait mechanics, such as walking with a shortened stride, favoring one side, or exhibiting a stiff or guarded gait. Signs of inflammation: Notice if there are any visible signs of inflammation, such as redness, swelling, or warmth, in the lower back area. | No swelling, no bruising tender to touch in the locally affected area.Range of movement: Range of motion（各大关节具体活动度总结）:https://naturaltherapysupplies.co.nz/?product=range-of-movement |
| TCM exam | Tongue: Dark Red Tongue with White CoatingPulse: Wiry | |
| Diagnosis | S572(N/A) Lumber Sprain (qi stagnation&blood stasis in Bladder Meridian) | |
| Treatment Principle | promote Qi and remove blood stasis to relieve the pain | |
| Today’s treatment | Example: 1)acupuncture 45mins – weizhong(L,R)-,chengshan(L,R),taixi(L,R)+Cupping -shenshu(L,R)10mins+Tuina in local 5mins 2) BL40(L),BL57(R),KI3(R,L)+Cupping -BL23(L,R)10mins+Tuina in local 5mins 3) Master tong’s points-Shou jie,Wan shun 4) Ashipoints around the Chize area based on Tan’s balance method theory Other treatment 1) Heat Lamp 45mins during the acupuncture treatment 2) Apply a heat pack or warm compress to the affected area for 15 minutes after acupuncture treatment to promote local circulation and relaxation. | |
| Post-treatment advice | 1. Instructions for home care, including self-care techniques or exercises 2. Recommendations for pain management, such as the use of heat or cold therapy 3. Precautions or lifestyle modifications to support recovery 4. Document the patient’s response to treatment, any changes in symptoms, and any adverse reactions experienced. 5. Advise the patient to avoid strenuous activities that may aggravate lower back pain. 6. Any referrals or follow-up appointments needed | 【simple template】 Avoid lifting heavy objects Keep the affected area warm 【detailed Template】 1. Encourage the application of ice packs for 30 minutes every 3 hours every day to reduce inflammation. 2. Suggest applying heat packs for 15 minutes after activities that may cause increased pain. 3. Recommend gentle range of motion exercises to prevent stiffness. 4. Encourage the patient to continue performing the prescribed range of motion exercises to maintain and improve lower back mobility. 5. Provide instructions for proper self-care and home management of the condition. 6. Instruct the patient to avoid strenuous activities that aggravate the pain, apply ice packs for 30 minutes several times a day, and perform gentle range of motion exercises to prevent stiffness. 7. Advise the patient to monitor any changes in symptoms and report any new developments or concerns during the following days. Others: The importance of rest and careful movement has been emphasised to avoid exacerbation of the injury. We will monitor the patient’s progress closely over the coming weeks and adjust the treatment plan as necessary. Follow up: 1. The patient is scheduled for her next appointment at the same time next week. The treatment efficacy and any changes in the patient’s condition will be evaluated during each visit. 2. The patient will return in two days for her next session. Regular reassessment of her pain levels sleep quality, and ROM will be conducted to monitor progress and adjust the treatment plan accordingly. 3. Schedule the patient for a follow-up appointment in one week to reassess the progress, modify the treatment plan if necessary, and evaluate the effectiveness of the acupuncture intervention. Review 1/52（约下一周）Go to the GP if getting worse |
| Plan(ACNZ病历上没有要求) | Review in 1 week.Re-check Ox measures as above. Repeat mobs if hasn’t achieved full ROM. Check whether she has achieved the goal of walking for 30mins pain-free. | |
| Patient Discharge(ACNZ病历上没有要求) | At the end of the treatment plan or when the patient ceases treatment. The patient’s status needs to be recorded whether there has been specific result or not. | 【examples】 1. The patient can walk freely without pain and can do all home duties as before. There is still back stiffness for an hour when arising in the morning. A summary and discharge have been sent to the referring doctor.2.Discharge with further advice on self-management |