Ketamine-Assisted Psychotherapy Clinical Documentation Handbook: Screening Forms, Session Notes, Monitoring Logs, and Compliance Templates for NPs and Therapists

Ketamine-Assisted Psychotherapy Clinical Documentation HandbookScreening Forms, Session Notes, Monitoring Logs, and Compliance Templates for NPs and TherapistsEvery ketamine clinic in the country needs standardized documentation, and most are operating without it. As KAP expands into a $3.4 billion market with over 1,500 clinics nationwide, regulatory scrutiny is intensifying. DEA audits target controlled substance records. Malpractice claims focus on screening gaps and monitoring failures. Insurance denials pile up when billing documentation is incomplete. The clinical work may be excellent, but if the paperwork cannot prove it, the practice is exposed.A Complete Clinical Documentation System Built for KAPThis toolkit provides over 100 reproducible clinical forms, templates, logs, and checklists covering every phase of ketamine-assisted psychotherapy, from initial screening through long-term follow-up. Each form includes clinical rationale, documentation guidance, and real-world examples showing how the documentation functions in practice. The system is designed for nurse practitioners, PMHNPs, psychiatrists, licensed therapists, and clinic administrators who deliver or manage KAP services.Screening and Intake DocumentationMedical eligibility screening with cardiovascular, hepatic, renal, and psychiatric risk assessment forms. Baseline symptom severity tracking using PHQ-9, GAD-7, PCL-5, C-SSRS, and CADSS-6. Layered informed consent templates addressing off-label use, route-specific risks, and telehealth addenda. Prior treatment failure documentation formatted for insurance justification.Session Documentation for Every RouteRoute-specific dosing records for sublingual, intramuscular, and intravenous ketamine. Real-time vital signs monitoring logs at 15-minute intervals. Adverse event tracking with rescue medication administration logs. Therapist observation templates and dosing-integration linkage forms that connect session content to therapeutic progress.DEA Compliance and Audit ReadinessKetamine inventory logs with running balance tracking. Drug waste documentation with witness protocols. Biennial DEA inventory templates. PDMP check logs. Storage security checklists. A comprehensive self-audit checklist mirroring the DEA inspection sequence. NDC codes, J-codes, and 2026 modifier references including the mandatory -JW and -JZ hard-stop enforcement.Billing, Telehealth, and Special PopulationsTime-based E&M documentation templates and MDM guides. Superbill generation templates with correct CPT and HCPCS codes. Telehealth-specific forms for at-home sublingual KAP including environmental safety assessment, remote vital signs logs, and sitter verification. Documentation addenda for older adults, trauma survivors, substance use disorder comorbidity, personality disorders, palliative care, eating disorders, and group KAP formats.Two Complete Sample CasesAppendices include two fully worked documentation examples showing every form completed from screening through follow-up: one sublingual telehealth patient and one intramuscular in-clinic patient. Plus blank reproducible copies of every form organized by treatment phase.Built for the clinical realities of 2026 KAP practice, this toolkit addresses the documentation gap that no EHR template, training program, or clinical manual currently fills. Read more