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PLAN:
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Medication Changes:
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Med Change Comments
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New Medication Rationale
• • •
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Continue Medication Rationale
• • •
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Taper Medication Rationale
• • •
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Ketamine Infusion
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esketamine (Spravato) Treatment
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LAB ORDERS
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Venous Puncture:
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Labs
• • •
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Lab Comments or other orders:
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Injections
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Cyanocobalamin Injection 1,000 mcg/mL
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Diphenhydramine HCl (Benadryl)
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Referrals
• • •
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Referral Comments
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Follow-Up
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Release of information
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Read
• • •
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General Instructions
• • •
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Education
• • •
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Education Comments
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Diet
• • •
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Diet comments
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GOALS:
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Standard Time Statement:
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Total Time with Patient in Minutes:
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SBIRT Time (Only charge if positive):
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Individual Therapy:
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Review of Testing:
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