Documentation is an essential requirement that all healthcare professionals must comply with. Actually, it maybe the most important way in following the progression of the patient. I cannot tell ho many times I had to refer to my old notes to better treat my patient. Documentation is very important to protect both the patient and clinician in any legal matters that come about.

The first thing the opposing attorneys want is the written progress notes and other specific medical documents that make up a patient’s chart. I am pretty sure that most of you know how the US healthcare system has turned into a system where suing as become commonplace. I often wonder if patients just want treatment to look for ways to sue the clinician. This is in fact a sad testament to our current US healthcare model.

I could write forever about the dangers of how attorneys are hampering our desire, as clinicians, to treat and care for the patient. However, in this blog, I want to discuss the challenges we, TCM practitioners, have in documenting. As with any other clinician, TCM practitioners are asked to keep very detail and organized notes.

Obviously, the content in these notes and the areas of focus is different than that of the Western-trained practitioner. Now, I am talking about documenting for a TCM that is covered by insurance. TCM clinicians do follow a similar method in documenting. Most clinicians are familiar with SOAP notes. We are trained to document our notes according to this format.

The variables making up our SOAP notes is considerably different than the ones that are used by our Western counterparts. The most obvious difference is the objective measurements that we use. In contrast to your typical Western blood pressure etc. objective measures, the TCM practitioner will document his findings in such measures as tongue diagnosis or pulse diagnosis…