Acupuncture Preprocedure Note

Patient presented to the Ambulatory Care Clinic to evaluate for for Battle

Field Acupuncture

Indication for procedure:

{FLD:ALLCOMMENT(2LINES)}

Previous pain management:

{FLD:ALLCOMMENT(2LINES)}

Anticoagulants: {FLD:X BOX}None {FLD:X BOX}Yes

{FLD:X BOX}Warfarin {FLD:X BOX}DOAC {FLD:ALL0001EDIT34}

{FLD:X BOX}ASA {FLD:X BOX}INR {FLD:ALL0001EDIT34}

Diabetes: {FLD:X BOX}None {FLD:X BOX}A1C{FLD:ALL0001EDIT34}

Allergy to Gold {FLD:X BOX}no {FLD:X BOX}yes

Wounds, infections {FLD:X BOX}no {FLD:X BOX}yes

Pregnancy {FLD:X BOX}no {FLD:X BOX}yes

Aversion to Needles {FLD:X BOX}no {FLD:X BOX}yes

Hx Vaso-Vagal {FLD:X BOX}no {FLD:X BOX}yes

Bleeding Disorders {FLD:X BOX}no {FLD:X BOX}yes

Battle Field Acupuncture

{FLD:X BOX}discussed the risks and benefits with the patient

{FLD:X BOX}described the procedure in detail

Exam

Right Ear

{FLD:X BOX}Normal

{FLD:X BOX}Erythema {FLD:ALL0001EDIT34}

{FLD:X BOX}Swelling / edema {FLD:ALL0001EDIT34}

{FLD:X BOX}Infections {FLD:ALL0001EDIT34}

{FLD:X BOX}Wound(s) {FLD:ALL0001EDIT34}

Left Ear

{FLD:X BOX}Normal

{FLD:X BOX}Erythema {FLD:ALL0001EDIT34}

{FLD:X BOX}Swelling / edema {FLD:ALL0001EDIT34}

{FLD:X BOX}Infections {FLD:ALL0001EDIT34}

{FLD:X BOX}Wound(s) {FLD:ALL0001EDIT34}

RECOMMENDATIONS / PLAN

{FLD:X BOX}No contraindications present

{FLD:X BOX}Patient agrees to Battle Field Acupuncture

{FLD:X BOX}Patient declines procedure

{FLD:X BOX}Acupuncture not advised due to contraindications noted above

==============================================================================

Procedure Note: Battle Field Acupuncture

{FLD:X BOX}An electronic permit for Battle Field Acupuncture was obtained,

signed by the patient and physician and entered into the patient’s electronic

record.

TIME-OUT PROCEDURE

Staff Present:

{FLD:ALLCOMMENT(2LINES)}

Immediately prior to the start of the procedure a time-out was taken:

The patient's identity was verified by asking for his/her

{FLD:X BOX}Full Name

{FLD:X BOX}His/Her Full Social Security Number

{FLD:X BOX}Date of Birth.

The procedure and sites were identified: Battle Field Acupuncture

{FLD:X BOX}The patient's identity, the sites of the procedure and the planned

procedure were verified by the staff and by the patient who were all in

agreement.

{FLD:X BOX}No contraindications to Battle Field Acupuncture are present (see

Preprocedure note).

{FLD:X BOX}The sites were NOT MARKED (not applicable)

PROCEDURE

The right and left external ears were cleansed with Chlorhexidine/alcohol.

Acupuncture Needles were placed in the locations marked below using ASP Gold

needles and the results noted:

Right Pinna Pin Result

1 Cingulate Gyrus {FLD:X BOX} {FLD:ALL0001EDIT34}

2 Thalamus {FLD:X BOX} {FLD:ALL0001EDIT34}

3 Omega 2 {FLD:X BOX} {FLD:ALL0001EDIT34}

4 Point Zero {FLD:X BOX} {FLD:ALL0001EDIT34}

5 Shen Men {FLD:X BOX} {FLD:ALL0001EDIT34}

Left Ear Pinna Pin Result

1 Cingulate Gyrus {FLD:X BOX} {FLD:ALL0001EDIT34}

2 Thalamus {FLD:X BOX} {FLD:ALL0001EDIT34}

3 Omega 2 {FLD:X BOX} {FLD:ALL0001EDIT34}

4 Point Zero {FLD:X BOX} {FLD:ALL0001EDIT34}

5 Shen Men {FLD:X BOX} {FLD:ALL0001EDIT34}

Improvement in pain level after Procedure: {FLD:X BOX}Yes {FLD:X BOX}No

If Yes: Improved from Pain level /10 to /10

Complications Noted:

{FLD:X BOX}None {FLD:X BOX}Bleeding {FLD:X BOX}Local pain

{FLD:X BOX}Vasovagal event {FLD:X BOX}Lightheadedness

Other : {FLD:ALLCOMMENT(2LINES)}

DISPOSITION:

You may remove the acupuncture pins without needing to return to the Clinic.

Some soreness at the site of the needles may occur.

Return to the clinic if redness, increasing tenderness or pain should develop

Follow-up with Primary Care Provider

Information sheet provided to veteran