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EIN/ NPI/ LICENSE
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Initial/ Sequential
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Infusion #
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Dose
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Magnesium
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Magnesium Dose
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Zofran
|
Zofran Dose
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Magnesium (Patient denies sentence)
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|
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S:
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SE:
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MSE:
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Appearance:
• • •
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A & O:
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Behavior:
• • •
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Speech:
• • •
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Affect:
• • •
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TP:
• • •
|
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Cognition:
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Insight
|
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Judgement
|
|
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Mood
• • •
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Mood (Patient Quote)
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SI:
|
SI
|
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Contracts for Safety
|
|
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HI
|
HI
|
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Psychosis
|
|
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Auditory Hallucinations
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Auditory Hallucinations
|
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Visual Hallucinations
|
Visual Hallucinations
|
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Injection Site
• • •
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# of Attempts/Site
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|
So2:
|
|
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So2 Initial:
|
So2 Discharge:
|
|
Blood Pressure:
|
|
|
BP Initial:
|
BP Discharge:
|
|
Heart Rate:
|
|
|
HR Initial:
|
HR Discharge:
|
|
Rating Scales:
|
|
|
PHQ-9 (Pre-Ketamine)
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GAD-7 (Pre-Ketamine):
|
|
PCL-5 (Pre-Ketamine):
|
McGill (Pre-Ketamine):
|
|
PHQ-9 (Post-Ketamine):
|
GAD-7 (Post-Ketamine):
|
|
PCL-5 (Post-Ketamine):
|
McGill (Post-Ketamine):
|
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N/V
|
Discharge Options
• • •
|
|
Patient fully recovered, alert, and oriented
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Discharged to:
• • •
|
|
Patient denies urinary/bladder symptoms
|
|
|
Diagnostic Impression:
|
|
|
DI: Major Depressive Disorder
• • •
|
DI: Other Disorders
• • •
|
|
DI: Bipolar
• • •
|
DI: Eating Disorders
• • •
|
|
DI- Substance Use Disorders:
• • •
|
DI- ADHD
• • •
|
|
DI: Cognition
|
DI: (If not listed as favorite above)
|
|
Alcohol/ Illicit Drugs:
|
If Pt uses alcohol/ illicit drugs, explain:
|
|
Medication Compliance:
|
If Pt is NOT medication compliant, explain:
|
|
Therapy after/before Infusion
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Therapy focused on
|
|
Plan
• • •
|
Additional Plan Notes:
|
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Follow Up
|
|
