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Guide for the American Board of Medical Acupuncture Case Reports
The case report is to provide adequate and logical medical information as well as to describe rational acupuncture medical management plans and outcomes. When preparing a case report, use clear and accepted medical language. You may use TCM terminology, if it genuinely guided your treatment approach, but always present the information in western medical terminology.
The case report should include the following:
Chief Complaints:
History of Present Illness:
Past Medical History:
Current Medications:
Allergies:
Family and Social History:
Review of Systems:
Physical Examination:
Diagnosis:
Treatment Plans:
Acupuncture Intervention: (Patient’s consent is required prior to acupuncture treatment.)
- Acupuncture rationale
- Style of acupuncture (e.g. body acupuncture, auricular acupuncture)
- Rationale for treatment (e.g. syndrome patterns, segmental levels, trigger points) and individualization if used
- Use literature sources to justify rationale when appropriate
- Needling details
- Acupuncture points utilized for the treatment (e.g. uni/bilateral)
- Needle type (e.g. gauge, length)
- Depths of insertion (e.g. cun or tissue level)
- Responses elicited (e.g. de qi or twitch response)
- Needle stimulation (e.g. manual or electrical)
- Needle retention time
- Treatment regimen
- Number of treatment sessions
- Frequency of treatment
- Usage of acupuncture related techniques
- Other interventions (e.g. moxibustion, cupping, herbs, gua-sha, acupressure, life-style advice)
Discussion: You may provide additional discussion of the case if you like. |
