Ketamine infusion for chronic pain

Form ID: ketamine_infusion_chronic_pain Type: Procedure Family: Infusion therapy

Structured fields

Section	Field	Key	Default layer	Required
Safety	Consent discussion	`consent_phrase`	Global Default	Required
Safety	Time-out and safety screen	`timeout_phrase`	Global Default	Required
Safety	Allergy / infection / anticoagulant screen result	`allergy_infection_anticoagulant_screen`	No Default	Required
Indication	Diagnosis / indication	`diagnosis`	No Default	Required
Indication	Clinical indication and failed conservative therapy	`clinical_indication`	No Default	Required
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
Outcome	Immediate response / pain score change	`immediate_response`	No Default	Required
Outcome	Complications / adverse event	`complications`	No Default	Required
Disposition	Post-procedure instructions	`post_procedure_instructions`	Global Default	Required
Disposition	Follow-up plan	`follow_up_plan`	Global Default	Required
Safety	Baseline vitals and mental status	`baseline_vitals`	No Default	Required
Safety	Pregnancy screen if applicable	`pregnancy_screen_if_applicable`	No Default	Optional
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
Outcome	Side effects / dissociation / nausea / emergence symptoms	`side_effects`	No Default	Required
Outcome	Immediate analgesic response	`immediate_response`	No Default	Required
Outcome	Complications / adverse event	`complications`	No Default	Required
Disposition	Discharge criteria met	`discharge_criteria`	No Default	Required
Disposition	Post-infusion instructions	`post_procedure_instructions`	Global Default	Required
Disposition	Follow-up plan	`follow_up_plan`	Global Default	Required

Section

Field

Key

Default layer

Required

Safety

Consent discussion

consent_phrase

Global Default

Required

Safety

Time-out and safety screen

timeout_phrase

Global Default

Required

Safety

Allergy / infection / anticoagulant screen result

allergy_infection_anticoagulant_screen

No Default

Required

Indication

Diagnosis / indication

diagnosis

No Default

Required

Indication

Clinical indication and failed conservative therapy

clinical_indication

No Default

Required

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

Outcome

Immediate response / pain score change

immediate_response

No Default

Required

Outcome

Complications / adverse event

complications

No Default

Required

Disposition

Post-procedure instructions

post_procedure_instructions

Global Default

Required

Disposition

Follow-up plan

follow_up_plan

Global Default

Required

Safety

Baseline vitals and mental status

baseline_vitals

No Default

Required

Safety

Pregnancy screen if applicable

pregnancy_screen_if_applicable

No Default

Optional

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

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

Outcome

Side effects / dissociation / nausea / emergence symptoms

side_effects

No Default

Required

Outcome

Immediate analgesic response

immediate_response

No Default

Required

Outcome

Complications / adverse event

complications

No Default

Required

Disposition

Discharge criteria met

discharge_criteria

No Default

Required

Disposition

Post-infusion instructions

post_procedure_instructions

Global Default

Required

Disposition

Follow-up plan

follow_up_plan

Global Default

Required

Narrative template

Ketamine Infusion for Chronic Pain

Indication: Ketamine infusion for {{diagnosis}}. {{clinical_indication}}

Consent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}} Baseline: {{baseline_vitals}} Pregnancy screen if applicable: {{pregnancy_screen_if_applicable}}

IV/protocol: Position: {{patient_position}}. IV access: {{iv_access}}. Protocol: {{infusion_protocol}}. Monitoring: {{monitoring}}

Medication/dosing: Product/concentration: {{ketamine_product}}. Lot/expiry: {{lot_expiry}}. Starting rate: {{starting_rate}}. Titration: {{titration_plan}}. Actual total dose: {{actual_total_dose}}.

Course: Intra-infusion vitals/events: {{intra_infusion_vitals}}. Rescue meds/equipment: {{rescue_meds_available}}. Side effects: {{side_effects}}

Outcome: Immediate response: {{immediate_response}} Complications: {{complications}}. Discharge: {{discharge_criteria}}

Disposition: {{post_procedure_instructions}} {{follow_up_plan}}

Physician review required before signing in the EMR. Verify actual medications, doses, lot/expiry, devices, image documentation, response, complications, and follow-up.