Form ID: ketamine_infusion_chronic_pain Type: Procedure Family: Infusion therapy
| Section | Field | Key | Default layer | Required | Quick text templates | History/exam sources |
|---|---|---|---|---|---|---|
| Safety | Consent discussion | consent_phrase | Global Default | Required | Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field. | |
| Safety | Time-out and safety screen | timeout_phrase | Global Default | Required | Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field. | |
| Safety | Allergy / infection / anticoagulant screen result | allergy_infection_anticoagulant_screen | No Default | Required | No known relevant allergies; no active infection symptoms; anticoagulant/antiplatelet status reviewed.; Medication/allergy list reviewed; no contraindication identified today.; Anticoagulant/antiplatelet plan reviewed and documented before proceeding.; Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field. | red_flags_neuro_screen; red_flag_exam_findings; current_medications |
| Indication | Diagnosis / indication | diagnosis | No Default | Required | condition_focus; pain_generator_impression; history_impression_plan | |
| Indication | Clinical indication and failed conservative therapy | clinical_indication | No Default | Required | Persistent function-limiting pain despite conservative management; procedure offered for diagnostic and/or therapeutic benefit.; Symptoms, examination, and available imaging are concordant with the planned target.; Prior treatment response and patient goals reviewed; patient wishes to proceed. | presenting_complaint; pain_location_distribution; functional_limitations; prior_treatments; imaging_labs_tests; pain_generator_impression; procedural_target_assessment |
| Indication | Laterality / side | side | No Default | Required | ||
| Setup | Patient position | patient_position | Per-Form Default | Required | ||
| Setup | Skin preparation | skin_prep | Global Default | Required | ||
| Setup | Sterile setup | sterile_setup | Global Default | Required | ||
| Setup | Monitoring | monitoring | Global Default | Required | ||
| Guidance | Guidance modality | guidance | Per-Form Default | Required | ||
| Guidance | Guidance documentation phrase | guidance_phrase | Global Default | Required | ||
| Guidance | Images saved / archive location | image_saved | No Default | Required | Representative images saved to clinic imaging archive.; Image storage not technically feasible; guidance findings documented in note.; Fluoroscopic images stored according to clinic workflow. | imaging_labs_tests; procedural_target_assessment |
| Outcome | Immediate response / pain score change | immediate_response | No Default | Required | Tolerated well; immediate response to be assessed over the expected therapeutic window.; No immediate complication; post-procedure pain/function response reviewed before discharge.; Immediate pain score and functional response documented after reassessment.; No immediate complication observed.; Response will be reassessed after the expected onset window. | history_impression_plan; exam_plan |
| Outcome | Complications / adverse event | complications | No Default | Required | None.; No immediate adverse event observed.; Transient expected procedural discomfort only.; No immediate complication observed.; Response will be reassessed after the expected onset window. | |
| Disposition | Post-procedure instructions | post_procedure_instructions | Global Default | Required | Post-procedure instructions and warning signs reviewed; patient advised to seek urgent care for concerning symptoms.; Activity modification, expected soreness, medication precautions, and red flags reviewed.; Written and verbal aftercare instructions provided according to clinic protocol.; Aftercare, red flags, and follow-up plan reviewed with patient. | |
| Disposition | Follow-up plan | follow_up_plan | Global Default | Required | Follow-up arranged according to response and treatment plan; patient advised to track pain, function, and adverse effects.; Reassess pain score, functional change, medication use, and adverse effects at follow-up.; Patient will contact clinic earlier for concerning symptoms or inadequate response.; Aftercare, red flags, and follow-up plan reviewed with patient. | history_impression_plan; exam_plan; patient_preferences_affordability |
| Safety | Baseline vitals and mental status | baseline_vitals | No Default | Required | Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field. | |
| Safety | Pregnancy screen if applicable | pregnancy_screen_if_applicable | No Default | Optional | Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field. | |
| IV | IV access | iv_access | Per-Form Default | Required | ||
| Protocol | Infusion protocol | infusion_protocol | Per-Form Default | Required | ||
| Medication | Ketamine product/concentration | ketamine_product | Per-Form Default | Required | ||
| Medication | Lot number and expiry | lot_expiry | No Default | Required | ||
| Dosing | Starting dose/rate | starting_rate | Per-Form Default | Required | ||
| Dosing | Titration plan | titration_plan | Per-Form Default | Required | ||
| Dosing | Actual total ketamine dose administered | actual_total_dose | No Default | Required | ||
| Monitoring | Monitoring | monitoring | Global Default | Required | ||
| Monitoring | Intra-infusion vitals / events | intra_infusion_vitals | No Default | Required | ||
| Safety | Rescue medications / equipment availability | rescue_meds_available | Per-Form Default | Required | Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field. | |
| Outcome | Side effects / dissociation / nausea / emergence symptoms | side_effects | No Default | Required | No immediate complication observed.; Response will be reassessed after the expected onset window. | |
| Outcome | Immediate analgesic response | immediate_response | No Default | Required | Tolerated well; immediate response to be assessed over the expected therapeutic window.; No immediate complication; post-procedure pain/function response reviewed before discharge.; Immediate pain score and functional response documented after reassessment.; No immediate complication observed.; Response will be reassessed after the expected onset window. | history_impression_plan; exam_plan |
| Outcome | Complications / adverse event | complications | No Default | Required | None.; No immediate adverse event observed.; Transient expected procedural discomfort only.; No immediate complication observed.; Response will be reassessed after the expected onset window. | |
| Disposition | Discharge criteria met | discharge_criteria | No Default | Required | Aftercare, red flags, and follow-up plan reviewed with patient. | |
| Disposition | Post-infusion instructions | post_procedure_instructions | Global Default | Required | Post-procedure instructions and warning signs reviewed; patient advised to seek urgent care for concerning symptoms.; Activity modification, expected soreness, medication precautions, and red flags reviewed.; Written and verbal aftercare instructions provided according to clinic protocol.; Aftercare, red flags, and follow-up plan reviewed with patient. | |
| Disposition | Follow-up plan | follow_up_plan | Global Default | Required | Follow-up arranged according to response and treatment plan; patient advised to track pain, function, and adverse effects.; Reassess pain score, functional change, medication use, and adverse effects at follow-up.; Patient will contact clinic earlier for concerning symptoms or inadequate response.; Aftercare, red flags, and follow-up plan reviewed with patient. | history_impression_plan; exam_plan; patient_preferences_affordability |
| Recommended next procedure | Recommended next procedure date | next_procedure_date | No Default | Required | ||
| Recommended next procedure | Medication choice | next_procedure_medication_choice | Per-Form Default | Required | ||
| Recommended next procedure | Dose | next_procedure_dose | Per-Form Default | Required | ||
| Recommended next procedure | Technique | next_procedure_technique | Per-Form Default | Required | ||
| Recommended next procedure | Patient position | next_procedure_patient_position | Per-Form Default | Required | ||
| Recommended next procedure | Premedication | next_procedure_premedication | Per-Form Default | Optional | ||
| Recommended next procedure | Pre-procedure comments | next_procedure_pre_procedure_comments | Per-Form Default | Optional | Reassess indication, response to current procedure, contraindications, patient preference, and affordability before proceeding.; Repeat only if clinically indicated after response and safety review.; Confirm medication/product availability, consent, and interval safety before booking. | history_impression_plan; exam_plan; patient_preferences_affordability |
| Recommended next procedure | Intra-procedure comments | next_procedure_intra_procedure_comments | Per-Form Default | Optional | Use same technique unless anatomy, response, or safety considerations require modification.; Adjust target/approach based on updated exam, imaging, and response to previous procedure.; Document any change in guidance, target, needle/cannula, or device settings. | |
| Recommended next procedure | Post-procedure comments | next_procedure_post_procedure_comments | Per-Form Default | Optional | Reassess response, adverse effects, function, and need for further treatment after the next procedure.; Track pain diary, functional goals, and medication change after the next procedure.; Review whether further repeat procedure remains appropriate before additional treatment. |
Physician review required before signing in the EMR. Verify actual medications, doses, lot/expiry, devices, image documentation, response, complications, and follow-up.