TCM Documentation II

…If you ask any TCM practitioner what the first thing that comes to his mind regarding documentation, he would most likely answer that it is a necessary evil. That is, it is something that needs to be done but is really is the most boring aspect of treating a patient. I think most of you would be empathetic to this opinion. I haven’t met one clinician who doesn’t think that documenting is their least favorite thing to do.

However, as I mentioned in the previous blog, documentation is the most important aspect to patient care. First of all, with proper documentation, the practitioner is able to examine his overall approach to treating the patient. He can see if the patient is actually progressing or not and then can make the necessary changes to the treatment protocol.

We, healthcare professionals, rarely appreciate this. I mentioned how the variables in TCM documentation are different than in Western medicine. I will write a lot more about the two key TCM objective variables, Pulse Diagnosis and Tongue Diagnosis, in future blogs. It is enough for you to realize that, as a TCM practitioner, I look at these variables as key to telling me how the patient is progressing.

Documenting the progression of these two variables is most important in determining whether the current treatment protocol is satisfactory or not. In fact, if I don’t see any change with these factors after a few treatments, I will change up the treatment plan. Again, this point is the reason why documenting accurately is so important.

You’ll be surprised how many healthcare practitioners do not share this view. I just have to point out their treatment success compared to mine. I tell any TCM practitioner that is just starting off that the most important way to be the most effective practitioner is to learn to document properly.