March 19, 2024

Streamline IV Ketamine Screening and Intake Documentation: A Guide for Clinicians

Written by

Alison McInnes, MD, MS

Are you thinking of seeing patients for IV ketamine? As a breakthrough treatment with approved off-label status by the FDA, proper documentation before, during, and after you see a patient is paramount.

The Ketamine Side Effect Tool (KSET) sets a gold standard in this domain with a comprehensive system for screening, baseline, acute treatment and follow-up assessments, using measurement-based care (Short et al., 2020). However, it’s hidden behind a paywall. For ongoing treatment documentation AFTER the initial intake, read this guide. The guide you’re reading now will provide you with the essential items you need to document prior to any ketamine administration.

Here’s a summary of what to include in your IV ketamine intake documentation:

  • Demographics: Capture a comprehensive snapshot of the patient's identity, including racial, ethnic, gender, and socio-economic details, is foundational for personalized care.
  • Detailed Psychiatric and Medical History: Be sure to inquire about psychiatric conditions that might be contraindicated for ketamine therapy including psychotic disorders and substance use disorders. Bipolar patients should be on a mood stabilizer.  Patients with PTSD or other stress-induced disorder may be more prone to distress during the infusion. Discuss in advance how they would like to be calmed if this occurs.  Focus on comorbid medical conditions of particular relevance for ketamine therapy chief among them, hypertension.
  • Medication history: Careful documentation of all previous and current psychiatric medication trials including augmentation trials and non-antidepressant medications. Also, if a patient discontinued their SSRI/SNRI recently, be sure that they are not suffering from a discontinuation syndrome that could complicate the assessment of treatment outcome. Such discontinuation syndromes can last weeks to months in the vulnerable.
  • Be sure to inquire specifically about medications that might adversely affect the outcome of treatment or may exacerbate ketamine induced hypertension and review  allergies or intolerances to medications potentially used during the infusion including nausea medicines. Also ask about the use of non-prescription drugs such as adderall as stimulants can exacerbate hypertension.
  • Pre-treatment Lab Tests: Emphasis on thyroid function, vitamin D levels, and liver enzymes.
  • Lab Tests and Urinalysis (UA): Baseline and follow-up tests are pivotal in monitoring the patient's health status and ensuring treatment adaptability.
    • Conduct follow-up tests during and post-treatment if symptomatic.
  • Brief physical exam including vital signs
  • Outcome Tracking: Employing regular surveys to gauge treatment efficacy not only enhances patient engagement but also solidifies the treatment's value proposition to stakeholders.

Now, let’s go over each section in more detail.

Setting the Stage Before IV Ketamine Administration

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

The Osmind EHR platform includes automated outcome surveys you can send to patients via a HIPAA-compliant app. These surveys, essential for documentation, measure treatment response.


Demographics are crucial for patient care. It goes without saying that you must be aware of your patient's racial and ethnic identity as well as pronoun preferences and gender identification. Level of education, employment status  and relationship status are also very important factors that will affect outcomes.

Next, let’s look at medical history, psychiatric history, and medical history and possible contraindications for ketamine IV treatments.

Medical History: Contrainidications to Look for Before Ketamine Treatment

The chief side-effect of ketamine, which is otherwise a very safe drug, is elevated blood pressure. This side-effect can sometimes be quite dramatic thus the clinician must screen for, any condition that could be exacerbated hypertension as listed here:  (ketamine ROS)

Pay particular attention to conditions that might be aggravated by hypertension, such as uncontrolled hypertension, aneurysms, stroke, or other cardiovascular diseases.

Osmind includes ketamine-specific note templates to save you time

Hemorrhagic Cystitis and Ketamine

Additionally, rare cases of hemorrhagic cystitis have been documented with chronic use of high dose ketamine, a condition flagged by the FDA to be on the increase. As we do not know for sure what dose, method of administration and cadence are absolutely safe, it’s crucial to be aware if your patient has a history of urinary tract infections. This is especially pertinent as psychiatric patients generally have a higher incidence of urinary tract issues.

BMI and Ketamine

Be sure to weigh your patient and calculate BMI. for BMI > than a certain threshold such as 36-40, clinicians might want to decrease the dose of ketamine for the initial infusion as increased incidents of extreme hemodynamic fluctuations and sedation complications may happen with obese patients when weight-based dosing is strictly adhered to.

Birth control/pregnancy and ketamine treatments

Ensure the patient is using a reliable method of birth control to avoid pregnancy and explain that the risk of repeated ketamine usage to a fetus is unknown.

Psychiatric history: Contraindications to Look for Before Ketamine Treatment

Please review all current and past psychiatric conditions. Inquire in general and specifically as follows:

  • Bipolar disorder: ketamine therapy can be a viable option, provided they're on a mood stabilizer to mitigate the risk of mania.
  • History of psychosis: generally psychedelic use is not encouraged in these patients.
  • History of trauma: ketamine can be very helpful for trauma but it is useful to know in advance if a patient is struggling with PTSD or a related condition as difficult material may emerge during treatment.
  • Evidence of serious characterological coping deficits, which are longstanding maladaptive patterns of behavior that may complicate response to treatment (note we used to call these personality disorders). It may be difficult to assess success of the treatment in these patients. Use clinical judgment here as a published study has show that ketamine can be used successfully in patients with borderline features.
  • Danger to self and danger to others. Specifically inquire about suicidal ideation (passive versus active) with chronicity and any attempts at self-harm and/or suicide. This is not a contraindication but extra vigilance is needed.
  • Family history: It is also useful to document any first degree relatives with a major psychiatric disorder or history of suicide attempt.
  • Explore current or past substance use and misuse. If appropriate, the clinician can also explain that unprescribed adderall used as a study aid should not be taken during treatment days. For ketamine to work optimally, the inhibitory neurotransmitter GABA must be suppressed. Both benzodiazepines and alcohol facilitate gaba-ergic neurotransmission and can thus impede the subsequent molecular cascade needed for the antidepressant response.

Medication History: Considerations for IV Ketamine Treatments

Careful consideration should be given to the patient's current and past medication, noting any use of:

  • MAOIs, stimulants (which could exacerbate hypertension during treatment) or benzodiazepines as mentioned.
  • Document effectiveness of the medication trial as well as the duration and dose of the trial.
  • Anti-hypertensives need to be continued.
  • Document any history of allergies including medications that might be given for nausea or elevated

Pre-treatment lab tests: Thyroid Function and Vitamin D Levels

Pre-treatment lab tests include but are not limited to a test of thyroid function (TSH) and vitamin D levels. These labs are required to rule out reversible medical causes of depression.  We encourage checking baseline liver function tests as there have been rare cases of elevated liver enzymes due to ketamine.

Baseline Vital Signs:  Heart rate, blood pressure and pulse ox.

Baseline urinalysis (UA), with follow-up tests during and post-treatment if symptomatic

Clinicians should take a baseline urinalysis before starting ketamine therapy for several important reasons:

  1. Kidney Function Assessment: Urinalysis helps evaluate the baseline kidney function of the patient. Since kidneys play a critical role in filtering and excreting waste products, it's crucial to ensure they are functioning properly before introducing any treatment that could potentially affect them.
  2. Detecting Urinary Tract Issues: Ketamine has been associated with urinary tract symptoms, including increased urinary frequency, urgency, and in severe cases, hemorrhagic cystitis. A baseline urinalysis can help identify any pre-existing urinary conditions that might be exacerbated by ketamine treatment. Establishing a baseline allows clinicians to monitor changes over time. If a patient develops urinary symptoms during or after ketamine treatment, comparing subsequent urinalysis results with the baseline can help determine whether the symptoms are related to the treatment.
  3. Overall Health Check: Urinalysis is a non-invasive way to check for a variety of health issues. It can detect signs of diabetes, liver disease, and infections, which are crucial for a comprehensive health assessment before starting any new treatment.
  4. Personalizing Treatment: Understanding a patient's baseline health status helps in tailoring the treatment plan. For instance, if a patient has a history of urinary issues, a clinician might adjust the ketamine treatment protocol or take additional precautions to monitor and mitigate potential side effects.

By conducting a baseline urinalysis, clinicians can ensure a safer and more effective treatment plan for patients undergoing ketamine therapy, addressing any potential risks proactively.

Regular outcomes measurement

Outcomes must be measured to maximize patient benefit, help engage them in treatment and justify the cost to insurers. Regular assessment once response has been obtained will allow you to detect potential relapse should that occur.

The Osmind EHR platform includes 40+ scales you can send to patients via a HIPAA-compliant app. These surveys, essential for documentation, measure treatment response.

Streamline Your Ketamine IV documentation and save valuable time 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.

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.

Watch Osmind's dedicated IV ketamine and SPRAVATO chart notes, with automatic REMS submissions in action:

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, leading to better outcomes.

A Comprehensive Solution for All Clinic Operations

Osmind caters to every clinic operational need, from calendar synchronization to payment processing. Integrated e-signature features, labs, EPCS, eRX, and virtual visits ensure a smooth patient experience and let you run your practice as flexibly as you want.

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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