Why state measurable outcomes?

Measurable goals (pain score, sleep hours, functional tolerance) let you and the patient track whether treatment is working and decide when to continue, taper, or refer. They also support your documentation and any insurance or referral communication.

Is this a medical diagnosis?

No. A TCM pattern is an East Asian medicine assessment, not a Western medical diagnosis or treatment of disease by a physician. The plan includes an acknowledgment to that effect, notes any physician referral, and reminds the patient they can decline or stop care. Refer out for red-flag or out-of-scope conditions.

How should I handle herbal recommendations?

Only within your state scope of practice and training. Document the formula considered, check for herb-drug interactions and contraindications (pregnancy, anticoagulants, etc.), and note that herbs are recommended after review. When in doubt, coordinate with the patient's physician.

Why state measurable outcomes?

Measurable goals (pain score, sleep hours, functional tolerance) let you and the patient track whether treatment is working and decide when to continue, taper, or refer. They also support your documentation and any insurance or referral communication.

Is this a medical diagnosis?

No. A TCM pattern is an East Asian medicine assessment, not a Western medical diagnosis or treatment of disease by a physician. The plan includes an acknowledgment to that effect, notes any physician referral, and reminds the patient they can decline or stop care. Refer out for red-flag or out-of-scope conditions.

How should I handle herbal recommendations?

Only within your state scope of practice and training. Document the formula considered, check for herb-drug interactions and contraindications (pregnancy, anticoagulants, etc.), and note that herbs are recommended after review. When in doubt, coordinate with the patient's physician.

Acupuncture Treatment Plan

A treatment-plan record for an acupuncture practice — patient and practitioner, presentation and Western/TCM diagnosis, treatment principle, point prescription, modalities, herbal/lifestyle recommendations, frequency and course of care, expected outcomes, and signature.

Customise

Clinic / practice name

Practitioner (L.Ac.)

Patient name

Date

Chief complaint / reason for visit

Western diagnosis / referral notes (optional)

TCM diagnosis / pattern

Treatment principle

Point prescription

Modalities

Herbal / lifestyle recommendations

Frequency & course of care

Expected outcomes / goals

Live preview

Still Point Acupuncture & Wellness
ACUPUNCTURE TREATMENT PLAN

Practitioner: Dr. Mei Tan, L.Ac., DACM
Patient: Alex Morgan Date: June 12, 2026

1. PRESENTATION
Chief complaint: Chronic low-back pain and stress; difficulty sleeping for 3 months.
Western dx / referral: Lumbar strain per PCP; no red-flag findings. Cleared for acupuncture.

2. TCM DIAGNOSIS (PATTERN)
Kidney Qi deficiency with Liver Qi stagnation; Qi and Blood stagnation in the lower back. Tongue: pale with thin white coat. Pulse: deep, wiry.

3. TREATMENT PRINCIPLE
Tonify Kidney Qi, course Liver Qi, move Qi and Blood, and relieve pain in the lower back.

4. POINT PRESCRIPTION
BL23, BL40, GB30, Du4, Huatuojiaji L2–L5, LV3, LI4, SP6, Yintang. Bilateral unless noted; retain 25–30 min.

5. MODALITIES
Filiform needling + electroacupuncture (2/100 Hz) to local points; cupping to lumbar paraspinals; moxibustion to Du4.
(Single-use sterile needles; clean-needle technique observed.)

6. HERBAL / LIFESTYLE RECOMMENDATIONS
Consider Du Huo Ji Sheng Tang if appropriate after review. Gentle daily walking; reduce prolonged sitting; warm compress to low back; sleep hygiene routine.

7. FREQUENCY & COURSE OF CARE
2x/week for 3 weeks, then re-evaluate; taper to 1x/week as symptoms improve. Reassess at visit 6.

8. EXPECTED OUTCOMES / GOALS
Reduce pain from 6/10 to <=3/10 within 4–6 visits; improve sleep to 6+ hours; restore comfortable sitting tolerance to 60 minutes.

ACKNOWLEDGMENT
Acupuncture and related modalities carry risks (e.g., minor bruising,
soreness, bleeding, or rarely other effects). This plan is based on a TCM
assessment and is not a diagnosis or treatment of disease by a physician.
The patient may decline or stop treatment at any time.

Patient: _______________________________ Date: ______________
Alex Morgan
Practitioner: __________________________ Date: ______________
Dr. Mei Tan, L.Ac., DACM

About this template

An acupuncture treatment plan turns the intake and diagnosis into a clear, documentable course of care — useful for the patient, for continuity between visits, and for your records as a licensed practitioner. The clinical spine of the plan is the TCM **pattern diagnosis** (the differentiation, with tongue and pulse), the **treatment principle** that follows from it, and the **point prescription** that carries out the principle — written specifically enough that you (or a covering practitioner) can reproduce the treatment. Around that, capture the **presentation** (chief complaint, plus any Western diagnosis or referral so care is coordinated and red flags are ruled out), the **modalities** (needling, electroacupuncture, cupping, moxibustion, gua sha) with a note that single-use sterile needles and clean-needle technique are used, and any **herbal or lifestyle** recommendations. Two parts make it a real plan rather than a snapshot: the **frequency and course of care** (how often, for how long, and when you will re-evaluate) and the **expected outcomes/goals** stated measurably (pain from 6/10 to ≤3/10 within 4–6 visits), which lets you track progress and adjust. Finally, an **acknowledgment** that records the patient understands the common risks, that acupuncture is not a physician's diagnosis or treatment of disease, and that they may decline or stop at any time. Keep records confidential (HIPAA may apply), document each visit against the plan, and work within your state's scope of practice — especially for herbal recommendations and any condition that warrants physician referral.

When to use it

Documenting an acupuncture plan of care after assessment.
Communicating diagnosis, points, and goals to the patient.
Coordinating with a referring physician.
Setting a treatment frequency and re-evaluation point.

What to include

Patient, practitioner, and date.
Presentation, Western diagnosis/referral, and TCM pattern.
Treatment principle and point prescription.
Modalities, herbal/lifestyle recommendations.
Frequency/course, measurable outcomes, and acknowledgment.

Frequently asked

The pattern differentiation — the syndrome(s) you identified (e.g., Liver Qi stagnation, Kidney Qi deficiency), supported by tongue and pulse findings. The treatment principle and point prescription should follow logically from it so the plan is internally consistent and reproducible.

⚠ Legal disclaimer. This acupuncture treatment plan is a general template, not legal or medical advice. Acupuncturists are licensed and regulated by state, with varying scope of practice (including herbal authority); single-use sterile needles and clean-needle technique are the standard of care, and acupuncture is not a substitute for physician diagnosis or treatment of disease. Patient health information may be subject to HIPAA and/or state privacy laws — store it securely. Practice within your scope and refer out when indicated.

Jurisdiction: United States — a clinical treatment-plan record for a licensed acupuncturist (L.Ac.). Acupuncturists are licensed and regulated at the state level; scope of practice, herbal authority, and supervision rules vary. Clean-needle technique (CNT) and single-use sterile needles are the standard of care. Patient health information is protected (HIPAA may apply; state privacy laws may apply broadly). Acupuncture is not a substitute for diagnosis or treatment of disease by a physician.

Last reviewed: 2026-05

Reviewed by ScoutMyTool — consult a licensed attorney for binding use.