Write what they used, what you told them, and what you did not start. That is the whole note. The FDA spent this week reminding ketamine sellers that a brochure is not an approval. Your chart should not pretend otherwise.
I am seeing this visit two or three times a week now. Someone’s cousin got infusions. A compounding clinic texted. They want to know if I “do ketamine” the way a med spa does ketamine. I do Spravato when it is indicated. I do not launder an Instagram ad into a plan.
What I put in the note
The sentence they used. “I bought lozenges from a site in Florida” is a fact. “Patient exploring interventional options” is how that fact dies.
The product, as named. Esketamine (Spravato) in a REMS chair is not racemic ketamine in a recovery suite, and neither is a troche from a telehealth company that never met them. If I cannot tell which one they mean, I ask, and I write the answer.
Whether I started, continued, declined, or referred. “Declined to prescribe compounded ketamine; discussed FDA-approved esketamine pathway and current evidence; no ketamine product added today.” If I skip that line, a covering NP will think I blessed it.
What I will not write
I will not copy efficacy language from a booth, a podcast, or a clinic that got an untitled letter. This week’s FDA letter to Alar Pharmaceuticals was about an investigational ketamine product presented at APA as if it were already a treatment. That is their problem. It becomes my problem if I echo it.
I will not put “ketamine, as discussed” in the plan when the discussion was “please don’t buy that.” The plan has to match the advice.
I will not add it to the med list because they asked. Asking is not taking. Taking belongs on the list, with whatever dose and route they will admit to, even if it is ugly.
The safety bits people skip
Last use, route, and whether they were alone. Dissociation in a medical setting is a protocol. Dissociation on a couch at 11pm is a different chart.
Blood pressure, bladder symptoms, urinary frequency, and whether anyone is driving them home if this is an in-clinic treatment. For a rumor-and-question visit, write that those were not assessed because no treatment was given.
If they are already on an MAOI, a high-dose stimulant, or they drink daily, that goes next to the ketamine sentence. Interactions do not live in a separate universe.
Spravato is still a different document
A REMS session has its own fields: start and stop, two-hour monitoring, blood pressure, how they got home. We already wrote a Spravato session guide. Do not mix that template with a “patient asked about ketamine” add-on in a med-management note. They are not the same visit.
If I refer to a certified program, I name the program or the city, not “interventional psych, TBD.”
Questions I get
Does off-label ketamine belong on the medication list? If they are taking it, yes. Source and dose as reported. If they only asked, it stays in the discussion.
Can I say I “support ketamine therapy” in the assessment? You can say you discussed evidence, access, and why this person is or is not a candidate for a specific product. “Support” is not a clinical sentence.
What if they already started at a clinic I don’t trust? Document the clinic as they named it, what they receive, last session, and what you are still responsible for (their SSRI, their sleep, their job). You can disagree in the assessment without rewriting their other doctor’s note from memory.