September 21, 2023

How to Write IV Ketamine Administration Notes (Template + Guide)

Written by

Alison McInnes, MD, MS

Ketamine intravenous therapy (KIT) lacks FDA approval, and no other regulatory body has endorsed definitive practice guidelines. For clinicians, this underscores the critical importance of proper documentation. It's paramount to ensure patient safety and address concerns from various stakeholders, including payers, malpractice insurers, and ketamine suppliers.

In this article, we'll guide you through everything you need to include in your IV ketamine treatment documentation. Here is a downloadable template to get you started.

What This Guide Covers:

  • What is an IV Ketamine Note?
  • The 3 Types of Notes to Consider
  • Overview of Intake Screening
  • Measurement-Based Care and Expected Outcomes
  • Elements Needed for Your First Ketamine Administration Note
  • Elements Needed for Every Ketamine Administration Note
  • Discharge Documentation

What is an IV ketamine Administration Note?

The typical course of IV ketamine is established as 4-6 infusions. To protect yourself and your patient, you'll need to consider 3 types of ketamine infusion administration notes throughout the course of treatment:

1. IV ketamine intake (full article coming soon)
2. Initial IV ketamine administration documentation (covered in this article)
3. IV ketamine documentation for every session (covered in this article)

Developing this Ketamine IV Note Guide: A Collaborative Endeavor

To address the need for standardized KIT documentation, we assembled a team of experts. This team, which reviewed our note templates, included distinguished individuals such as:

  • Dr. Patricio Rive Posse, the developer of the renowned KSET—a benchmark for evidence-based guidelines on ketamine administration.
  • Dr. Sandhya Prasad, a psychiatrist and president of ASKP3.
  • Charles Miller, CRNA and owner of Scenic City Neurotherapy.
  • Daniel Sternthal, JD from Munsch Hardt, a specialist in healthcare regulation.

While the comprehensive nature of KSET’s guidelines is acknowledged, many seek a more concise yet thorough resource. This guide meets that need, ensuring clarity without sacrificing depth.

What This Guide Isn't (Our full ketamine intake guide can be found here)

This guide doesn't delve into the specifics of a ketamine intake note. As detailed by KSET, such an intake note should be completed prior to any ketamine administration. It must cover:

  • Full demographics
  • Detailed psychiatric and medical history, focusing on conditions contraindicated for ketamine therapy
  • Medication history, emphasizing contraindicated medications and reviewing allergies or intolerances to medications potentially used during the infusion
  • Pre-treatment lab tests (e.g., thyroid function, vitamin D levels, and liver enzymes)
  • Baseline urinalysis (UA), with follow-up tests during and post-treatment if symptomatic
  • Substance abuse history, specifically noting prior misuse of ketamine or other prescription drugs
  • Regular outcomes measurement

On our Osmind platform, outcome surveys are sent to patients via a HIPAA-compliant app. These surveys, essential for documentation, measure treatment response.

Before initiating treatment, you should administer surveys to adopt a measurement-based care (MBC) approach. MBC provides a clear patient baseline, fostering personalized treatment and liability protection. Ideally, send surveys before and after the standard treatment course, which typically consists of 4-6 infusions administered within a maximum of 28 days.

Step 1: Set the Right Expectations with Patients

Before starting the therapeutic journey, it's vital to set clear expectations for your patients. Inform them about potential outcomes, reinforcing trust.

Consider the findings from our groundbreaking studies, which are among the largest real-world studies on KIT to date:

  • McInnes et al. 2022: Published in the Journal of Affective Disorders, this study underscored ketamine's efficacy in treating depression. Boasting a significant effect size of 1.5, a remarkable 70% of participants reported improved suicidal ideation from baseline. Moreover, 80% maintained their responder status a month later. Explore the full study here.

  • Hietamies et al. 2023: This broader study, incorporating anxiety outcomes, reinforced the findings of McInnes et al. 2022. Over half of the participants noted a 50% reduction in symptoms of both depression and anxiety. Impressively, of the initial 80% reporting suicidal ideation, 70% saw improvements, with half experiencing no such thoughts post-treatment. This research also identified a 'late responder' subgroup, 20% of the study's participants, showing improvements between the 10th and 12th infusions—a finding consistent with Oliver et al. 2022. Delve deeper into the findings here.

Use these studies to reassure patients that IV ketamine's effects on depression and anxiety are consistent over time, with the treatment's efficacy remaining stable even with repeated administrations.

What should you Include in your initial IV ketamine administration documentation?

These are the elements you need to include in your first administration note (after you've already done an inital intake and eval):

  • Consent: A consent form is vital. However, having an abundance of consent forms can be counterproductive if they aren't meticulously reviewed. Discuss consent in-depth during the intake and revisit it during the first infusion. Update consent forms every six months to reflect the latest developments.
  • Comprehensive Ketamine ROS: Conduct this only during the intake and the first note. Despite its thorough nature, there's no need for repetition. Remind patients of ketamine's potential misuse risks during intake and the initial session.
  • Pregnancy/Breastfeeding: Confirm that the patient isn't pregnant or breastfeeding (needed only in the first note). Document your counseling session advising against conception during ketamine treatments if they aren't on birth control. Reiterate this advice if a patient returns after a hiatus.

What should you include in every subsequent IV ketamine administration note

These are the elements you need to include in every note:

  • Routine Documentation
  • Patient Description/Response: Begin every note with a concise patient description and treatment goals, which may evolve. Detail any treatment responses at the top of subsequent notes.
  • Medication Check: Before the infusion, verify if any contraindicated medications were withheld. This list might include benzodiazepines, non-benzodiazepine sedative-hypnotics, psychostimulants, and monoamine oxidase inhibitors (MAOIs). Always verify any new medications started since the previous session.
  • Mental Status: Conduct a mental status exam (MSE) before each session. This is critical to ensure the patient has reverted to their baseline mental status, a crucial evidence piece in malpractice claims.
  • Vital Signs and Dosing: Confirm that vital signs are within the acceptable range before commencing the infusion. Document dosing details, including weight considerations, dose in mg/kg, and infusion duration. Note infusion start and end times, any used boluses, and the time of the last recorded vital signs—these serve as discharge vitals to show the patient's post-infusion return to baseline.
  • Side Effects and PRN Medications: Document any observed side effects during the session, rating their severity as mild, moderate, or severe. Also, record any medications administered to manage these effects. Common side effects might include dissociation, nausea, vomiting, dizziness, headache, sedation, numbness, and tingling.

What should you include in your IV Ketamine discharge documentation?

After a patient finishes a course of IV ketamine treatment, they've gone through often intesne mental and emotional changes. Before you discharge them, you need to cover your bases to ensure they're safe and ready to suspend treatment.

Here's a checklist of what to consider before discharging a patient:

  • Addressing Side Effects: Confirm resolution of all session side effects. If dissociation was observed using CADSS-6, note in the discharge summary that the patient no longer exhibits it.
  • Blood Pressure: It's vital to match a patient's discharge blood pressure with their baseline.
  • Dosage Alteration: If a patient experiences moderate to severe acute side effects or if these effects linger post-treatment, avoid increasing the dosage in the next session.
  • Mental Status: Ensure you document the patient's return to their baseline mental state. If suicidal ideation was reported before treatment, you must assess it before discharge and provide a safety plan if necessary.
  • Ambulatory Status: Document the patient's departure from the clinic, specifying if they left unassisted or needed help. This is crucial for malpractice claim defense.
  • Responsibility: Releasing a patient post-treatment is a significant responsibility. If a patient drives or encounters issues during a car ride post-treatment, the clinic might bear liability. Confirm that a responsible adult escorted the patient home.
  • Discharge Instructions: Ensure the patient comprehends the discharge directives, especially the critical instruction not to drive until the following day.
  • Follow-Up Plans: Always outline the plans for the upcoming session and provide the clinic's contact details for any queries or if symptoms intensify.

How to Streamline Ketamine IV Documentation with Osmind

When it comes to mental health treatments, your clinic deserves a specialized Electronic Health Record (EHR) system. Osmind delivers precisely that—an EHR crafted with ketamine clinics' unique requirements in mind. Our system offers a harmonious blend of clinical precision and patient-centered tools, enabling you to concentrate on care while we manage the intricacies.

Watch: See how Osmind's ketamine note template and SPRAVATO® note template save you time and protect you and your practice:

Why Choose Osmind for Your Clinic's Primary Ketamine EHR
Osmind's unique Ketamine IV chart note streamlines your documentation process. Seamlessly capture all essential details, from infusion timings to patient vitals. Created in collaboration with top clinicians and grounded in evidence-based practices, we prioritize patient safety and compliance.

Elevate Patient Engagement and Experience
Our intuitive patient app features over 40+ rating scales, automatically updating your dashboard. With capabilities like secure messaging, journaling, and auto-submission of superbills, your patients stay engaged and informed, augmenting their overall experience and treatment results.

A Comprehensive Solution for All Clinic Operations
Osmind caters to every clinic operational need, from calendar synchronization to payment processing. Integrated e-signature features and automatic superbills ensure a smooth patient experience and efficient clinic management.

The Advantages of Osmind for Your Ketamine Clinic at a Glance:

  • Specifically designed for ketamine clinics
  • Consistently top-ranked in the mental health EHR category
  • A trusted ally for a vast array of ketamine clinics
  • Supported by a respected leadership team deeply involved in ketamine research

Let us show you how Osmind let's you focus on the heart of your mission: delivering exceptional patient care.

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