Objectives: The aim of this research was to identify any unique and routine procedural elements of clinical acupuncture as practiced by professional practitioners and educators in Japan. Additionally, to describe these methods in detail and examine how they related to philosophical concepts, diagnostic methods and treatment principles. Methods: An ethnographic methodology was employed to collect data during long term fieldwork in Japan. Participants were recruited through chain referral and emergent sampling. Data was collected by observing and interviewing practitioners and educators of acupuncture in Japan. Patient records and other relevant documents were also collected and together with recordings from observations and interviews, were analyzed thematically. Results: Over four years, 32 participants were recruited from prefectures all over Japan. Of these, 19 agreed to clinical observation, 16 to participate in formal interviews and 14 in informal interviews; 217 treatments were observed with 168 different patients. In relation to treatment principles, one especially interesting theme was interpreted from the data: practitioners tended to confirm the effects of interventions during treatment. Effects were confirmed on three different levels of timing and location: micro, meso and macro. Important markers for change included practitioner perceived needle sensations and muscle tension. Discussion/Conclusion: Micro, meso and macro level confirmation play different roles during the therapeutic encounter. That treatment effects can be can be almost immediately palpated or observed influences a number of clinical factors including point selection methods, treatment tool manipulation techniques and needle retention time. The solicitation of tangible change demonstrates pragmatism and importance in practitioner skills as a catalyst for therapeutic change in Japanese acupuncture.