How HIM Can Help
MANY CONDITIONS may be treated effectively with integrative medicine. For each listed below, HIM professionals can play
different roles in developing and standardizing documentation and coding.
Diagnosis or
Chief Complaint
Acute GI Pain
Asthma symptoms
Cancer pain
Chemotherapy induced N&V
Fibromyalgia
Infertility
Major depressive disorder
Migraine
Neck Pain
Osteoarthritis of the knee
CHD – Prevention
Post-operative pain
Pregnancy induced N&V
Pre-operative anxiety
Evidence-Based Support for
Treatment of Diagnosis or
Symptom
Acupuncture
Yoga, breathing techniques
Acupuncture, massage
Acupuncture, relaxation training
Massage therapy
Acupuncture
Aerobic exercise, yoga
Acupuncture, massage,
meditation, MBSR, biofeedback,
relaxation training
Acupuncture
Acupuncture
Transcendental meditation, yoga
Acupuncture
Acupuncture
Ear acupuncture; acupuncture,
meditation
EHR Standardized
Format
Development
X
X
X
X
X
X
X
X
X
X
X
Documentation
Guideline
Development
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Coding Guideline
Development
X
X
X
X
X
X
X
X
X
X
X
X
Source for columns 1 and 2: The American College of Physicians’ Evidence-Based Guide to Complementary & Alternative Medicine by Bradly Jacobs, MD, MPH,
and Katherine Gundling, MD, FACP. Philadelphia: ACP Press, 2009.
care. As a result, a shared understanding of all documentation
practices in the health record is essential.
Acupuncturists have a specific methodology for documenting
care. The most common acupuncture treatment is the insertion
of acupuncture needles at specific points along energetic lines
on the surface of the patient’s body, known as meridians. These
meridians are named for major organs in the body such as the
lung, liver, kidney, and bladder. Each meridian contains a different number of acupuncture points; there are more than 365
acupuncture points on the body.
The acupuncturist documents the insertion of each needle using the meridian acronym and the point number. For example,
if a needle is inserted on the 67th point of the bladder meridian
on both the left and right sides of the body, the acupuncturist
will document B-BL67 in the patient’s record. The first B represents “bilateral” and the BL represents the bladder meridian.
Even if a physician or other healthcare professional caring for
a patient can interpret this information, it is still important for
them to know where on the patient’s body BL67 is located. The
location for BL67 is on the outside of the pinky toe, near the nail,
and it is one of the most powerful points on the body. BL67 is
used, among other things, to turn a breech baby’s position while
in utero, and has been documented as an effective treatment for
breech presentation.
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This is just one example of the need for some level of standardization of documentation for licensed acupuncturists providing
services in hospital settings. As integrative medicine therapies
continue to grow in healthcare systems, it is essential to develop
a standard for documentation across all healthcare disciplines.
Patient Use and Understanding of Integrative Health
Information
Concerns around integrative medicine health records involve
patients as well as practitioners. In a recent study, acupuncture
patients were found to be less knowledgeable about their health
records and less confident about asking their practitioner for
