Psychiatry
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approximately 14 views since I made an informed decision.
Date:[date name="date" default=""]
Phase of Spravato treatment:
[select name="phase" value="induction|every week|every two weeks"]
Session #
[text name="variable_1" default=""]

CONCOMITANT MEDS
Benzodiazepines:
[radio name="variable_1" value="yes|no"]
Non-benzodiazepine sedative hypnotics:
[radio name="variable_2" value="yes|no"]
Psychostimulants:
[radio name="variable_3" value="yes|no"]
MAOIs:
[radio name="variable_4" value="yes|no"]

Pt was administered
[select name="variable_5" value="24 mg|56 mg|82 mg"] of esketamine via intranasal insufflation in clinic today under my direct medical supervision.
Esketamine administration was observed by:
[text name="variable_6" default=""]

Time at start of administration (24h format):
[text name="variable_17" default=""]
Time when pt completed treatment session (24h format):
[text name="variable_18" default=""]
Was the patient clinically ready to leave prior to the required 2 hours?: [radio name="ready" value="yes|no"]
[conditional field="ready" condition="(ready).is('yes')"]Minutes ready after administration: [text name="minutes"][/conditional]

Initial BP:
[text name="variable_7" default=""]
BP at 40 min post administration:
[text name="variable_8" default=""]
BP at discharge from clinic:
[text name="variable_9" default=""]

Pt experienced sedation: [radio name="sedation" value="yes|no"]
[conditional field="sedation" condition="(sedation).is('yes')"]Onset of symptoms from start of administration:[radio name="sedation" value="1-29 mins|30-59 mins|60-89 mins|90-120 mins|greater than 120 mins"][/conditional]
Pt experienced dissociation: [radio name="dissociation" value="yes|no"]
[conditional field="dissociation" condition="(dissociation).is('yes')"]Onset of symptoms from start of administration:[radio name="dissociation" value="1-29 mins|30-59 mins|60-89 mins|90-120 mins|greater than 120 mins"][/conditional]
Pt experienced SAE: [radio name="SAE" value="yes|no"]
[conditional field="SAE" condition="(SAE).is('yes')"]SAE [text name="SAE" default=""]
Occurrence
[radio name="occurence" value="During this treatment session|Since the last treatment session"]
Date of Event
[date name="SAE date" default=""]
This event resulted in:
[checkbox name="variable_1" value="hospitalization|disability or permanent damage|medical intervention|life-threatening|death"]
Did the event resolve?
[checkbox name="resolve" value="yes|no"]
[/conditional]

Pt left the clinic stable after treatment and with a ride:
[radio name="variable_16" value="yes|no"]
Return to clinic:
[select name="days" value="2-3days|one week|two weeks"]
Date:
Phase of Spravato treatment:

Session #


CONCOMITANT MEDS
Benzodiazepines:

Non-benzodiazepine sedative hypnotics:

Psychostimulants:

MAOIs:


Pt was administered
of esketamine via intranasal insufflation in clinic today under my direct medical supervision.
Esketamine administration was observed by:


Time at start of administration (24h format):

Time when pt completed treatment session (24h format):

Was the patient clinically ready to leave prior to the required 2 hours?:


Initial BP:

BP at 40 min post administration:

BP at discharge from clinic:


Pt experienced sedation:

Pt experienced dissociation:

Pt experienced SAE:


Pt left the clinic stable after treatment and with a ride:

Return to clinic:

Result - Copy and paste this output:

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