A reflection on writing case records: development and current demands for acupuncture practitioners

The written case that reflects the course of treatment for a person is central to the East Asian medical tradition. This paper examines the approaches and particularities of producing the actual written account of the clinical encounter, or a particular aspect of a case, that may be required by acupuncture practitioners and researchers. It will discuss the influences that can be brought to bear on the construction and production of these accounts. In addition, it will outline and highlight historical approaches to the case record documentation process as well as debate the value and purpose of these. This paper aims both to assist the production of helpful and authoritative case records for practitioners and researchers, and to highlight the usefulness of such case records. Moreover, it will discuss not only why the case needs to be written and for whom, but also which agencies support and control what is written. How can contemporary requirements and traditional views both be incorporated accurately, with context and with meaning? The essence of this paper is that practitioner/patient interactions need to be documented, and it will explore how this can best be supported.