Acupuncture and Chinese Medicine Clinical Student Handbook

Patient Charting & Record Maintenance

The patient’s chart is a medical record and a legal document. Charting of patient treatments must be carried out in an accurate, concise and consistent manner. Depending on the specific site, documentation and chart storage will differ and may include electronic of hand copy health records.

A patient folder is a legal document. All patient medical records should be accurate documentation of the patients’ health history and treatments. They are not to be removed from the clinic and may not be copied except upon request by the patient. The single exception to this is that Interns may copy non-identifiable sections of the file in order to create case histories as are requirement for a NWHSU course. As a legal document, charts must comply with the laws governing the use and confidentiality of patient information. The following standards pertain to clinical expectations regarding charting expectations and clinical file maintenance.

All files require the following elements:

  • Signed Teaching Clinic and Acupuncture Informed Consent Form
  • Patient Health History Questionnaire
  • Patient Medication and Supplement Chart
  • New Patient and Follow-Up Treatment Notes
  • HIPAA forms
  • Cancellation Policy
  • Signed Consent Form for Treating a Minor (if applicable)
  • Case Notes Summary/Telephone Conference Form (if applicable)

A record must be made of every telephone call with the patient. Log the time, day, nature of their concerns, and your recommendations to the patient.

In on-site NWHSU and community clinics, clinical staff will provide initial patient documents. It is ultimately the responsibility of the clinical supervisor and the clinical intern to ensure all clinical documentation is complete and appropriate signatures obtained.

The following are ACM charting expectations for paper charting at external community clinics:

  • All material should be charted in black ink or blue ink if on paper.
  • All entries must be legible
  • Always include first and last name of patient and the complete month, day and year of visit.
  • Record all data, positive and negative, that contribute directly to your assessment. This data should include detailed notes on the patient’s health, history and examination, pulses and tongue, and any other palpatory findings, evaluation of progress, diagnosis and/or change in diagnosis, treatment strategy and treatment details including points treated and herbal formulas prescribed.
  • Make sure entries cannot be interpreted more than one way
  • Document evidence of any patient non-compliance or patient misconduct. See also NWHSU policy.
  • Review and update the Patient Medication and Supplement Chart at each patient visit.
  • Record all recommendations that are made, including diet, exercise, or referral to other licensed practitioners.
  • Record the concerns of your patient or their family.
  • When treating with cups and/or guasha, reiterate to the patient the information outlined in the Teaching Clinic Informed Consent regarding the possibility of skin abrasions. When treating a minor with cupping or guasha, fill out the Informed Consent for Treatment of a Minor. The form must be signed by the parent or guardian. Give one copy to the parent or guardian and place one copy in the patient’s file.
  • Always document accidents, injury, or other unusual or distressing incidents that occur during the course of a treatment such as fainting during acupuncture, moxa burns, or bruises from the needles.
  • Use the Clinical Incident Report form to record these occurrences on the day of the incident. Give copies of the report to the Associate Dean of Clinical Services and to the NWHSU Clinic Administrator.
  • Never destroy, rewrite, or replace a prior record. If a notation must be corrected, draw a single line through that part that must be changed; the corrected part must remain legible. Do not use white out. Initial and date the change.
  • Both the intern and the supervisor must sign each day’s notes and treatment plan, after the supervisor has reviewed it, and print their full names next to their signatures.
  • All forms and treatment notes must be attached to the patient file in chronological order.
  • Patients are to receive written instructions with all herbal prescriptions. Pre-printed dispensary labels should be filled out and attached to all powdered and raw herbal prescriptions.
  • Patients are to receive written instructions with any items that are sent home with the patient, e.g., moxa, intradermal needles, press tacks or ear beads, or diet recommendations.

Patient records are reviewed each week (NWHSU on-site clinics of DRC and NHC-B), and at least once each semester for signatures, accuracy, and completeness. A regular review of the patient records ensures that records are complete at all times. Patient record keeping is a part of each student’s performance review in clinic, and figures into the overall grade for reach clinical internship.

Patient Communication Outside the Treatment Room

From time to time students may need to follow up with patients to learn about treatment efficacy or otherwise learn about the patient’s experience post-treatment. Occasionally a student may call a patient they haven’t seen for a long period of time, and ask if they want to schedule another appointment. These contacts are to be made only with the supervisor’s approval. Do not contact patients for any patient- related care, from any source outside of the clinic space – all contact related to a patient’s care must be done while in the clinic using on-site phones. This does not apply to referring friends or potential patients to call the clinic for an appointment.

While in clinic you may experience working with patients who are also friends, family members, or acquaintances. These “dual roles” occur in our profession and require extra awareness to maintain ethical boundaries, especially in social situations. While in a social setting such as a party or a grocery store, never initiate any interaction regarding the treatment room.

Protocol for Handling “Treatment Reaction” Calls

Patients occasionally have treatment reactions and may call to express their concerns. Whether onsite at a NWHSU clinic, or offsite at an external host clinic, the Clinic Reception Desks will take the information and present it to the Clinic Supervisor on duty at the time OR call to the NWHSU Chair of Clinical Education. If the call happens on the same shift or at a time when the intern is present, the Clinic Intern may speak with the patient at the time of the call in order to listen to their concerns. The patient will be advised that the student Intern will consult with the supervisor and then get back with them.

Students will pull the patient’s chart and then approach the Clinic Supervisor on shift to discuss the concern. After receiving input from the Clinic Supervisor, the Clinic Intern may relay this information to the patient.

  1. If you have been asked to handle the call, please consider the following guidelines:
  2. If it is an Emergency, refer the patient to the Emergency Room and have them call 911.
  3. If it is not an Emergency, listen receptively and take explicit notes.
  4. Be a compassionate listener, but do not express your opinion regarding their situation.
  5. If the Student Intern who treated the patient is not available, the Clinic Reception Desk will present the information to an available Clinic Supervisor who will then choose a Clinic Intern to handle the situation.
  6. Discuss the reaction with the Clinic Supervisor.
  7. Chart your discussion with the Clinic Supervisor in the patient’s chart.
  8. Return the phone call to the patient and chart both your conversation and their conversation.
  9. All phone calls to patients must be conducted from a phone line provided for that purpose. Interns are not allowed to contact or respond to a patient regarding their treatment unless they have received input from a Clinic Supervisor.

Conversing with Other Health Care Practitioners

Conversations between health care practitioners regarding NWHSU patients seen either on campus or at external host sites, must take place between the Supervisor and the conferring health care practitioner.

The procedure to be followed when there is a conversation regarding a NWHSU patient is:

  1. The patient must sign a release form giving permission for a NWHSU Supervisor to speak with another health care practitioner concerning the patient’s health condition.
  2. The patient is told to invite the other health care practitioner to call the appropriate NWHSU supervisor directly, or the NWHSU clinic to arrange a time for the phone conference.
  3. The NWHSU front desk will schedule the call for the beginning of the clinic shift in which the supervisor and intern work. The receptionist notifies the supervisor and the intern via e- mail.
  4. The conversation is to take place on speaker phone in the supervisor’s office. The supervisor and intern will call the practitioner at the appointed time. The phone call will be approximately 5 minutes in length.
  5. The conversation is to be between the supervisor and the conferring health care practitioner.
  6. The intern treating the patient is to be present during the conversation but is not to speak unless asked by the supervisor to speak.
  7. The intern is to chart notes of the conversation.

Making Referrals

In treating patients, a Student Intern may become aware of conditions that may require a referral. The Student Intern should discuss the condition with the Clinic Supervisor to determine the necessity and appropriateness of referral and to whom to refer. The Clinic Supervisor has the responsibility of making the referral.

To determine the appropriateness of a referral, the following may be helpful:

  1. What are the symptoms? Do the symptoms represent a red flag such as risk of suicide, extreme pain, profuse bleeding, or broken bone?
  2. Any discussion, implication, or hint to the Student Intern that a patient is in danger of committing suicide should be immediately reported to the Clinic Supervisor. The Clinic Supervisor will decide if a call to 911, the patient’s therapist (if they have one), an emergency “help-line,” or a family member is in order.

Student Interns work with the Clinic Supervisor who makes the referral to a Licensed Health Care Provider.

Per MN Statue 147B Subd. 6, referral to other health care practitioners is required when an acupuncturist practitioner sees patients with potentially serious disorders including, but not limited to:

  1. cardiac conditions including uncontrolled hypertension;
  2. acute, severe abdominal pain;
  3. acute, undiagnosed neurological changes;
  4. unexplained weight loss or gain in excess of 15 percent of the body weight in less thana three-month period;
  5. suspected fracture or dislocation;
  6. suspected systemic infections;
  7. any serious undiagnosed hemorrhagic disorder; and
  8. acute respiratory distress without previous history.

The acupuncturist shall request a consultation or written diagnosis from a licensed physician for patients with potentially serious disorders.